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Understanding Sensory Dysfunction

of related interest
Sensory Perceptual Issues in Autism and Asperger Syndrome
Different Sensory Experiences Different Perceptual Worlds

Olga Bogdashina
Forewords by Wendy Lawson and Theo Peeters
ISBN 1 84310 166 1

Sensory Smarts
A Book for Kids with ADHD or Autism Spectrum Disorders Struggling
with Sensory Integration Problems

Kathleen A. Chara and Paul J. Chara, Jr. with Christian P. Chara

Illustrated by J.M. Berns
ISBN 1 84310 783 X

Kids in the Syndrome Mix of ADHD, LD, Aspergers, Tourettes,

Bipolar and More!
The one stop guide for parents, teachers, and other professionals

Martin L. Kutscher, with contributions by Tony Attwood and Robert R. Wolff

ISBN 1 84310 810 0
ISBN 1 84310 811 9

Aspergers Syndrome
A Guide for Parents and Professionals

Tony Attwood
Foreword by Lorna Wing
ISBN 1 85302 577 1

Communicating Partners
30 Years of Building Responsive Relationships with Late-Talking Children
including Autism, Aspergers Syndrome (AS), Down Syndrome, and
Typical Development
Developmental Guides for Professionals and Parents

James D. MacDonald
ISBN 1 84310 758 9

Understanding Sensory Dysfunction

Learning, Development and Sensory Dysfunction
in Autism Spectrum Disorders, ADHD, Learning
Disabilities and Bipolar Disorder

Polly Godwin Emmons and

Liz McKendry Anderson

Jessica Kingsley Publishers

London and Philadelphia

Diagnostic criteria for pervasive developmental disorder not otherwise specified, autistic disorder and
Aspergers disorder on pages 6972 reprinted with permission from the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Copyright 2000. American Psychiatric Association.
First published in 2005
by Jessica Kingsley Publishers
116 Pentonville Road
London N1 9JB, UK
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
Copyright Polly Godwin Emmons and Liz McKendry Anderson 2005
Second impression 2005
Third impression 2006
The right of Polly Godwin Emmons and Liz McKendry Anderson to be identified as authors of this work has
been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced in any material form (including
photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally
to some other use of this publication) without the written permission of the copyright owner except in
accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a
licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1T
4LP. Applications for the copyright owners written permission to reproduce any part of this publication
should be addressed to the publisher.
Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for
damages and criminal prosecution.
Library of Congress Cataloging in Publication Data
Emmons, Polly Godwin, 1960Understanding sensory dysfunction : learning, development and sensory dysfunction in autism spectrum
disorders, ADHD, learning disabilities and bipolar disorder / Polly Godwin Emmons and Liz McKendry
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-84310-806-1 (pbk.)
ISBN-10: 1-84310-806-2 (pbk.)
1. Sensory integration dysfunction in children. 2. Developmentally disabled children. 3. Learning disabled
children. 4. Autism in children. 5. Attention-deficit hyperactivity disorder. 6. Manic-depressive illness in
children. I. Anderson, Liz McKendry, 1961- II. Title.
RJ496.S44E465 2005
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN-13: 978 1 84310 806 1
ISBN-10: 1 84310 806 2
ISBN pdf eBook: 1 84642 150 0
Printed and Bound in Great Britain by
Athenaeum Press, Gateshead, Tyne and Wear

To Laura, a daughter to treasure and a wonderful sister.

To Dylan, a son to cherish and a devoted brother.

To Richard, for his continued support of all of my endeavors.
To Lindy, Ellie, Julia, and Carter, who bring me my greatest joys.


We thank our families and friends who have been listeners and
supporters throughout this project. A special thank you to Eileen, who
cared enough about our children, and our families, to throw us a lifeline
when we most needed it; and who encourages us to continue to see the

What we would like the reader to take away from this book
The ultimate goal


What is Sensory Integration?

A brief history of sensory integration
Sensory processing
The sensory systems
The developmental timeline
Social and emotional development and sensory integration
Development as viewed through a sensory lens


What is Sensory Dysfunction?

Signs and symptoms
Dysfunction in the sensory systems
Logans day
Sensory dysfunction through the developmental stages
The functional areas as viewed through a sensory lens
Assessment and evaluation
Programs and services


Concomitant Diagnoses
What is an autism spectrum disorder?
What are learning disabilities?
What is ADHD?
What is bipolar disorder?
To medicate or not to medicatethis is the question


Sensory Dysfunction at School

Everyone has a job to do
What special education is, and is not
The players on a childs team
Analyzing possible sensory dysfunction and offering solutions
The teacher as detective
Home/school partnerships
Adapting to the child


At Home and at School: Looking at Strategies

Management techniques
Considering and modifying the environment
Self-care strategies








More About Aspergers Syndrome

Diagnosing Aspergers from the DSM-IV: Selecting from the menu
Social and communication deficits: Pragmatics made easy
Colins day


Ellie and Dylan: Ten Years Later

Ellies story (part one)
Ellies story (part two)
Dylans story (part one)
Dylans story (part two)

In Conclusion













A decade has passed since we first felt compelled to share our stories as
mothers of children with sensory dysfunction. Now the feeling has gripped
us once again to continue the story and advocate for the children with sensory
processing difficulties, for the parents, for the teachers. As the years have
passed, we find ourselves evolving both personally and professionally. In
1995, when we were writing Unlocking the Mysteries of Sensory Dysfunction
(Anderson and Emmons 1996), we wrote from the perspective of parents of
young children with significant sensory issues, and we were struggling to
keep our heads above water. These were supposed to be the salad dayswhile
the best was yet to come. However, the dream did not always match the reality.
When our paths crossed, we instinctively realized that our individual struggles and the challenges our children presented were perhaps reflective of a
common issuesensory dysfunction.
In Unlocking the Mysteries of Sensory Dysfunction, we shared our early
journey into a world where there was very little information (thank goodness
for A. Jean Ayres and her book Sensory Integration and the Child (1979)) about
children with sensory issues. We then began to consider the relationship
between sensory dysfunction and other diagnoses such as ADHD, learning
disabilities, autism spectrum disorders, psychiatric disorders, cerebral palsy,
Down syndromethe list goes on and on. We were aware that sometimes the
sensory issues were the big piece and other times they were the small piece
or were negligible. We had to face the facts that while we had very different
children and very different lifestyles, the commonalities were simply too
powerful to be attributed to chance. It started off as two moms talking in a



waiting room while our children received early intervention services, sharing
our experiences, and beginning to search for more information. It then
became our mission to become more informed and more actively involved.
We both called everyone we knew; we still came up with very few resources.
We read all of the clinical/medical stuff on sensory dysfunction (with dictionary in hand) and started calling authors and others considered experts.
Once we gathered as much information as we could find, we began to translate this information in terms of our own lives, what seemed applicable and
appeared to have the most relevance. We did this because we felt we needed to
help our children, ourselves, and our families, and ultimately to help and
support other children with sensory issues and their families. The collection
of symptoms we were seeing in our children was simply not going away.
Rather, it was morphing and changing, but certainly not just going away. This
was true for our children and other children as well. This was a life-altering
realization! Our subsequent work in homes, schools, and community
organizations only serves to validate and reaffirm this commitment.
In retrospect, it is those early experiences and struggles that continue to
define and sculpt who we are both personally and professionally as mothers
and as teachers. Back in 1992, we had few role models or real direction as to
where we were going and what we should do for our children with sensory
dysfunction. At that point in our lives, whether or not to have our children
evaluated, the evaluation process itself, the need for and access to services, and
just everyday family life were often overwhelming. Yet these early experiences
were a great motivator that ultimately prompted us to go with our gut
feelings, continue to seek information and objectively to begin to document
what we were seeing in our own children. It was in fact their sensory dysfunction that ultimately drove us to seek further evaluations Dylan was diagnosed in 1995 with Aspergers syndrome. Ellies evaluation in 1996 was
highly suggestive of PDD-NOS, and in 2002 she was diagnosed with
ADHD and mood disorder. In addition, Lizs son, Carter, was diagnosed with
central auditory processing disorder, ADHD and multiple learning disabilities
in 2001. For Dylan, Ellie, and Carter, as with many children, their sensory
dysfunction continues to be at the very core of who they are and how they
respond to the world around them.
As we began to observe and document Ellie and Dylans behaviors, back
in the early 1990s, we started becoming aware of patterns of behavior in
children (and adults!), and began to seek out other parents who had similar
concerns about their children, attempting to fit the pieces together.



What we would like the reader to take away from this book
We have been the parents of children with sensory dysfunction for a long time
(over 15 years) and have been challenged, not only by their sensory issues, but
by time spent chasing down appropriate programs, services, and diagnoses.
It has not always been easy, but it certainly has been a learning process for us.
Instead of being tempted to simply judge and move on, we now look at our
children, and other children, with a more caring and analytical eye. As
teachers, our multiple credentials and certifications have allowed us to teach in
public and private schools. We have taught general education classrooms,
special education classrooms (self-contained and inclusion), and in integrated settings from early intervention through 12th grade. As we strive to
gain new knowledge and experience, we also strive to bring our expertise and
compassion into our work.
We hope you read this book with an open mind and an open heart. This
book is not intended to be diagnostic, scholarly, or judgmental. This book is
about possibilities and potentialities and things to ponder and to consider
regarding sensory issues or sensory integration dysfunction. This book is
about being authentic and realistic when dealing with children, families, and
schools. We want to recognize and acknowledge that your reality can be
very different depending on your circumstances. For example, you might be
in the position of affording private schools, private therapists, and designing a
sensory room for your child. Or you might be in the position where your
child attends an under-funded school, one occupational therapist services the
entire district and your three kids share a bedroom. Different issues face
parents and teachers depending on whether they are in a rural, suburban or
urban setting. And we realize that most people are doing the best they can
under the circumstances they find themselves in. It is our experience that in
most cases teachers and parents want what they feel is best for a child,
whatever that may be.
Our focus in this book is to create a greater awareness of the behaviors
and symptoms associated with sensory integration dysfunction and sensory
issues, and to empower people by providing information. We are all about
giving concrete strategies that are designed to be as effective, efficient, and
practical as possible. We feel compelled to say right here, right now, that this
book is not about looking at every behavior as a sensory issue or seeking
services for every child with a mild sensory issue. Rather, we will focus primarily on the children with a high enough degree of sensory dysfunction that
it interferes with learning, relationships, and other skill development. Most



likely, these are the kids who will need some type of strategies or interventions. These are the kids who will often receive some services, a classification,
and a diagnosis of some kind. Whatever it is you are looking for, we hope this
book helps you in finding it.

The ultimate goal

Our ultimate goal is for each child with sensory dysfunction to reach his or
her potential.
From a parents perspective, this may be happiness, academic achievement, friends, popularity, athleticism, membership in groups or clubs, a
drivers license, college, marriage, owning a home, having a family, or a fulfilling career. Or it may be daily living skills, basic communication skills, a friend,
an IEP diploma, supported employment, a good nearby group home, adaptive
sport to participate in, being invited to social gatherings, or having somewhere to go for the holidays. In this book, we assert that many parents will
benefit from developing a framework for dealing with the decisions, goals,
and direction for the lifetime of their child. The parental goals for a child at 7
months old, 7 years old, 17 years old, or 27 years old and beyond will change
and evolve; just as with any child. Parents plan ahead and do their best, then
try to be flexible with whatever actually comes along.
From a teachers perspective, success may mean academic success, behavioral compliance, appearing happy, acceptance by peers, positive attitude,
strong work ethic, supportive family, participation in extracurricular activities, and attendance at school functions.
With the parents and teachers perspectives in mind, the question then
becomes, how will each adult in a childs life craft the framework for a plan
that is considered to be achievable, functional, and realistic, and will contribute to a childs internal compass: who she is, where she is going, and how she
is going to get there. Often children with sensory processing difficulties
exhibit sensory distortion, which can contribute to a strong sense of internal
The ultimate goal of this book is to help children with sensory dysfunction and the adults in their lives gain a better understanding of themselves as
they attempt to understand the world around them. We hope that this book
provides useful information and insights to help in achieving this goal.
In the following chapters, we will discuss some ways to tease apart what
might be attributed to sensory dysfunction, the importance of early identifi-



cation, and possible home and school strategies and interventions. As you read
this book, we encourage you to reflect on your own personal framework
regarding sensory integration and possible dysfunctionwhat you already
know, what you already are doing, and what information may be most helpful
to you.

Chapter 1

What is Sensory Integration?

Sensory integration is a childs ability to feel, understand, and organize

sensory information from his body and his environment. In essence, sensory
integration sorts, orders, and eventually puts all individual sensory inputs
together into a whole brain function. When the functions are whole and
balanced, body movements are highly adaptive, learning is easy, and good
behavior is a natural outcome. Sensory integration is also reflected in a childs
development, learning, and feelings about himself. The connection between
sensory integration and social and emotional development should not be
underestimated! How a child integrates through the sensory systems provides
a basis for his reality. Not your reality, not my reality, his realityand his unique perspective on the world around him.

A brief history of sensory integration

About 35 years ago, A. Jean Ayres, an occupational therapist, was working
with children and adults with neurologically based disabilities, when she
began to realize that some of the difficulties her clients were experiencing
were going beyond obvious physical impairments to subtle attention difficulties and learning difficulties that were impacting all areas of their
livesschool, community, and home. Dr. Ayres began to focus her efforts on
these children with perceptual learning and behavioral problems that could
not be attributed to known causes. She believed that the best answers would
be found in a better understanding of how the brain processes sensationsnot only from the eyes and ears, but from the other parts of the body as




well. Dr. Ayres believed that sensory integration occurs automatically in most
people, so we just take it for granted. While many people have now become
used to thinking of the brain as directing all activity in the body and mind, the
concept of sensory integration continues to introduce a new way of looking at
learning and behavior.
Briefly, in her book Sensory Integration and the Child (1979), Dr. Ayres
described the nervous system as an interconnected network of nerve cells that
are distributed throughout the body. The brain and the spinal cord together
are known as the central nervous system. Basically, the central nervous system
is responsible for taking in sensations from outside (and inside) the body,
sending signals to the brain where they are organized and processed, where a
response is formulated and sent. So, according to Dr. Ayres,
Sensory Integration is the organization of sensation for use. Our
senses give us information about the physical conditions of our
bodies and the environment around us. Sensations flow into the
brain, like streams flowing into a lake. Countless bits of sensory
information enter into our brains every momentthe brain locates,
sorts and orders sensationssomewhat as a traffic policeman directs
moving cars. When sensations flow in a well organized or integrated
manner, the brain can use those sensations to form perceptions,
behaviors and learning. When the flow of sensations is disorganized, life can be like a rush hour traffic jam. (pp.45)
So, it is sensory integration that attempts to put it all together and that helps
us make sense of who we are and the world around us.
For us, as mothers, Sensory Integration and the Child was a challenging but
incredibly eye-opening book. It gave us a lifelinefinally, someone who
seemed to understand our children and give us an explanation for why they
behaved the way they did. It truly changed the way we viewed our children
and their odd behaviors. This was our first realization that our children were
simply wired differently, and that there was something we could do about it.
We figured that if we could just gain an understanding of sensory integration
dysfunction, it would enable us to interact more positively and effectively
with our children and become better advocates for their needs; and, most
importantly, there was hope that we could improve the quality of their lives!
We came to find out that our children were not just willful and difficult,
but were doing the best they could from moment to moment. Dr. Ayres was
one of the first to recognize that some childrens nervous systems are just not



as stable as other childrens, making them more emotionally fragile; that too
much noise, confusion, demands, changes in routines, or illness can cause
them to lose control of their emotions. It was important for the people in their
lives to sense when this was going to happen and help our children to cope.
Other current theory and practice surrounding sensory integration
appears to illustrate several common principles that we think are also important to note. These include:

The central nervous system seems to contain a degree of plasticity.

In other words, certain areas of the brain may be able to compensate or take over functioning for another part. For example, a
toddler suffers a head injury and loses his speech; the plasticity of
the brain may be able to kick in, with the toddler ending up with
near age-appropriate language development.

Sensory integration usually develops sequentially and

hierarchically (the old adageyou have to crawl before you can
walk, you have to walk before you can run). For example, you
have to have hand and mouth awareness and a functioning pincer
grasp before you can feed yourself finger foods.

People have an inner drive to attempt to organize their ability to

integrate and will often seek sensory input subconsciously. For
example, a child may suck her thumb or twirl her hair to calm
herself and regroup.

Sensory input influences adaptive behaviors. These behaviors

may, in turn, generate additional sensory-based behaviors. For
example, a child is learning to swing. He learns that by pumping
his legs harder, the swing goes higher and he begins to
experience a different degree of sensory input or swinging

Sensory processing
Sensations are the way that we take in information from our environment
(internally and externally) and then process them to make sense of what is
going on in us and around us. What makes sensory processing so complex is
that it is not an all or nothing thing. No one is really perfect at sensory processing, and most people have some ability to integrate through at least some
of their senses. An example of someone who might be considered to possess
good sensory processing might be an Olympic gymnast. An example of



someone who might be considered to possess poor sensory processing might

be an individual with severe autism. So, in essence, we are looking on a
sensory integration spectrumsensory processing along a continuum. To
help people gain a better understanding of how sensory input is processed,
professionals often break sensory processing down into different components; for example, sensory registration, sensory modulation, and sensory response.
To clarify these terms, we will refer to sensory registration as the conscious or
unconscious perception of one or more sensory signals; sensory modulation
as the modification or alteration of the perception of a sensory signal (e.g.,
level of arousal) before it is processed for appropriate action; sensory response
as the behavior that is driven by the integration of the registration and modulation of the sensory input. The following provides a brief look at a few
examples of behaviors you might see in a child experiencing difficulties with
sensory processing.

Difficulties with sensory registration: may appear under-reactive to

movement or touch, can appear lethargic, may exhibit a delayed
response to sensory input. Or may appear over-reactive to
movement or touch, may exhibit heightened response to sensory

Difficulties with sensory modulation: may be upset with changes in

routine, have a high level of distractibility, have a high activity
level, experience difficulty with transitions, or may appear
detached, withdrawn or shutdown.

Difficulties with sensory response or integration: may have problems

with motor planning, may have a poor quality of motor responses
(especially controlled motor responses and/or protective
responses), may have poor body awareness, may have trouble
coordinating the two sides of the body.

Some professionals include sensory defensiveness when addressing some of the

common sensory processing problems. A child showing sensory defensiveness may resist or even strongly refuse certain types of activities or touch, may
appear to be very emotionally labile or fragile, may be considered to have
odd or unusual eating habits or be considered a picky eater or a difficult child at meals.
In other theories, sensory processing has been broken down into different
components. For our purposes, we prefer to break down sensory processing
into the following components:



registration of sensory input

orientation to sensory input
interpretation of sensory input
organization of a response to the sensory input
execution of response.

It is important to note that these components in sensory processing will be

influenced by several other factors, including the modality (the channel it
took), the intensity (how strong it was), the duration (how long it lasts), and
the location (where it occurred) of the sensory input.
Understanding the role and importance of sensory processing can
become increasingly important as you begin to take a closer look at behavior
with perhaps a different approach to interpreting it. Two examples:
A 6th grader, Michael, is standing in line waiting for a turn at the water
fountain after gym, when another student accidentally brushes his shoulder
(sensory registration). Now, Michael has to figure out where on his body this
sensation came from (orientation), then decide what it wasan accidental
brush, light tap, hit, punch, or stab (interpretation). Michael perceives this
sensory input as an accidental brush and pauses to glance behind him (organization of a response). Michael then continues to wait for his turn (execution
of a response). How might you have interpreted this behavior if you had not
considered the importance of sensory processing? How might you interpret
this behavior now? Is it the same? Is it different?
A 6th grader, Marco, is standing in line waiting for a turn at the water
fountain after gym class when another student accidentally brushes his
shoulder (sensory registration). Now, Marco, has to figure out where on his
body this sensation came from (orientation) and then decide what is
wasaccidental brush, light tap, hit, punch, or stab (interpretation). Marco
perceives this sensory input as a hard punch in the middle of his back. So,
Marco quickly spins around with a clenched fist in the air (organization of a
response). Marco loudly and furiously threatens to find the kid who punched
him and punch him back (execution of a response). How might you have
interpreted this behavior if you had not considered the importance of sensory
processing? How might you interpret this behavior now? Is it the same? Is it



Sensory integration is what turns sensation into perception. Perception

defines reality to an individual! Again, sensory integration defines reality, not
your reality, not our reality, his realityand his unique perspective on the world around

The sensory systems

Most people are familiar with the five senses:

touch (or tactile)

smell (or olfactory)
taste (or gustatory)
hearing (or auditory)
seeing (or visual).

However, some people remain unfamiliar with the sensory systems: tactile,
vestibular, and propioceptive. Not only is it critical that these sensory systems
function properly, but also that they work well together. If the tactile, vestibular, and proprioceptive systems cannot function efficiently, either separately
or together, it directly affects a childs ability to interact successfully within
him or herself, with others, and in his or her surroundings.

The tactile system

The tactile system is our sense of touch. This system allows us to feel
hot/cold, sharp/dull, rough/smooth. The tactile system allows us to find
(discriminate) objects by touch (feeling around in an overloaded purse for a set
of keys). This information also includes light touch, pain, and texture and
pressure. To better understand this, hold out your hand with your palm facing
the floor and tickle the back of your hand. Now, turn your hand over and
tickle the palm side. Notice a difference in your sense of touch? For most
people the palm has a much higher degree of sensitivity to touch.

The vestibular system

The vestibular system coordinates the movement of the eyes, head, and body
through space and body movement. The vestibular system allows us to
balance, swing on a swing, coordinate the two sides of our body, and catch
ourselves when we stumble. Just for fun, stand up, close your eyes, spin quickly



three times in one direction, three times in the other direction, keep your eyes
closed, and try to stand on one foot. Thats your vestibular system at work!

The proprioceptive system

The proprioceptive system uses unconscious information from the muscles
and joints to give awareness of body position. It is the feedback from muscles
and joints that allow us to stand without falling, use a pencil or bounce a basketball. An example of this is to put your arm out to the side and turn your
head in the opposite direction. Now bend your arm. How do you know you
arm is moving? You cant see it because your head is turned the other way. You
cant taste it, smell it, hear it, or touch it. You know because the sensations
from your muscles and joints are giving you the information.
We believe that it is imperative to have an understanding of how sensory integration is supposed to workhow it is supposed to look when all the
systems are up and running and working well together, in order to recognize
and begin to identify the behaviors and symptoms that may indicate sensory

The developmental timeline

Looking back, we had early indications that our infants were struggling in the
course of natural development. While we were told by family and friends that
it was just a difficult baby or late blooming toddler, our gut feelings told
us that it was something moresomething we didnt completely understand
and something certainly we could not name. The developmental timeline
provides that basis upon which many parents, caregivers, daycare providers,
teachers, and pediatricians base their expectations. A look at the timeline will
indicate a range of what is considered typical development and help begin
to tease out what may be an early indication of atypical development.
The following is an informal timeline for birth to age 5. It is not meant to
be regarded as a rigid timetable for the acquisition of skill development;
rather, it is our way of providing some general guidelines to create a greater
awareness of skills generally considered to be within the normal range of
child development. This timeline is a compilation of many different developmental guidelines and our direct observations. We present the information
with the understanding that cultural norms vary and may influence a childs


03 months

Responds to voice
Vocalizesbabbles or coos when talked to
Smiles spontaneously
Reaches for dangling ring
Follows movement by turning head
Startles at loud noises
Wriggles and kicks with arms and legs
Raises head when lying on tummy
Demands to be fed
Grasps objects placed in hand
Enjoys bath (splashes, kicks, lifts head)
Enjoys looking at bright things

36 months

Reaches for familiar persons

Laughs aloud
Discriminates strangers
Picks up a cube
Rolls from stomach to back
Holds head up without support
Reaches for objects
Turns head toward sounds
Babbles and squeals
Plays with rattle and teething toys
Wriggles in anticipationfrolics when played with




69 months

Imitates speech sounds

Pulls out peg
Uncovers toy
Stops activity when hears no, no
Waves bye-bye
Creeps or crawls
Responds to own name
Stands with support
Hits two objects together in imitation
Takes spoon-fed baby foods
Likes to bang, throw, and drop things
Reaches persistently for things out of reach
Becomes interested in exploring a variety of toys
Sits unsupported and erect for one minute

912 months

Says Mama, Dada

Looks at pictures in a book
Holds a crayon
Uses two words besides Mama and Dada
Indicates wantsvocalizing, reaching
Plays Peek-a-boo
Finger-feeds self
Cruises holding onto furniture
May be beginning to walk with or without support
Initiates play



Plays Pat-a Cake, So Big and ball games

Shows tenderness toward doll or stuffed animal
Begins to show preference for toys, begins to choose deliberately
Begins to play games with understanding

1218 months

Fetches or carries familiar objects

Shows things when named

Uses names of familiar objects

Points to named body parts
Follows one-step directions
Points to pictures in books
Plays with other children (parallel play)
Refers to self by name
Asks for food when hungry
Matches familiar objects
Recognizes reflection in a mirror
Initiates own play activities
Tries putting on own shoes
Feeds self with spoon
Lets wants and needs be known by vocalizing, word
approximations, single words, reaching, pointing, grasping

Picks up a finger food with pincer grasp

Begins to show range of emotions
Crawls upstairs on hands on knees
Kneels without support



1824 months

Stacks two to three small blocks in imitation

Walks well
Says about ten words (18 months)
Listens to short stories
Says about 25 to 50 different words (24 months)
Concentrates intently while playing with toys
Likes to lug, dump, push, pull, and pound
Carries and hugs soft doll or teddy bear
Enjoys blowing bubbles, nesting toys
Can string a large wooden bead
Can manage small indoor steps and slide
Imitates adult activity
Seats self in small chair
Walks downstairs with one hand held
Indicates a wet or soiled diaper

2430 months

Sometimes uses two-word phrases

Joins in nursery rhymes and songs

Copies another childs play

Walks up and down stairs with help (two feet per step)
Can do simple inset puzzles
Likes pull toys, push toys, pile-up toys, sandbox, water play,
hammering toys, hidden object toys

Shows and imitates names for additional body parts

Names common objects
Helps put things away


Associates use with objects

Prefers action toystrains, telephones, cars, riding toys

Observes other children at play and joins in briefly

Recognizes self in photos
Plays simple group games like Ring around the rosy
Is eager for new toys
Begins to exhibit a capacity for pretend play
Plays relatively well with older children
Imitates more of the adult behaviors
Is not yet able to share own toys without adult assistance
Much play is accompanied by words
Likes building with blocks, taking them down, filling and
dumping containers, taking things apart, and putting things

Can fit several different shapes into shape sorting box

Stacks five rings on spindle in correct order
Plays happily with different textures, temperatures
Participates more in self-dressing

3036 months

Can point out three items in a picture

Begins to develop independence from parents

Can sort objects by one category (color, size, shape)

Knows the concept of one
Can select an appropriate object from a group of many when

Begins to develop sense of humor, plays tricks

Begins to learn to take turns





Talks to and can be understood by unfamiliar people

Can feed self (using spoon) without helpmay still be messy

Can button and unbutton
Engages in more pretend play
Play expandsboxes, musical instruments, puzzles, blocks, etc.
Enjoys climbing through tunnels, playing in tents (sheet over
table), having a basket to carry things in

Uses three-word (or more) sentences

Becomes conversational
Kicks a ball
Names body parts
Strings large objects
Copies simple letter formation strokes

The fourth year (ages 34)

Shows preferences for certain activities (trikes, blocks, art, puzzles,


More sophisticated dramatic play

Matches and sorts by size, shape, color

Can take turns

Completely dresses self (not tying shoes)
Balances on one foot
Names some colors
Counts three objects
Is curious about the why and how of things
Emerging literacy (looking at labels, a book is more than just
pictures, etc.)


Knows stories, rhymes, and jingles, and is anxious to repeat

Asks questions
Is aware of feelings of self and others
Begins to use fork effectively
Language easily understood by unfamiliar listeners
Strong food, play, and activity preferences

The fifth year (ages 45)

Has definite opinions about toys, likes, and dislikes

Enjoys dressing up like superheroes
Enjoys scissors, jigsaw puzzles, a wider variety of toys
Traces or prints names
Counts from one to ten (or beyond)
Expanding pre-literacy and pre-writing skills
Follows through on project more than one day
Participates in complex, sustained dramatic play
Is becoming competitive
Can dress and undress self without guidance
Toilet-trained day and night
Ties shoes
Begins to use knife
Follows three- or four-step directions
Draws a person with six to eight body parts
Conversational reciprocity, speech intelligibility near 100%
Cooperative play




Catches a bounced or thrown ball, can track or kick a moving


Knows part or all of his address

Social and emotional development and sensory integration

Earlier in the book, we made reference to the role that sensory integration
plays in social and emotional development in children. Often social and emotional behaviors provide valuable clues that a child may be experiencing
sensory integration issues or dysfunction. Two areas of social-emotional
development that immediately come to mind are temperament and social
interaction. By reflecting on the following questions, you may gain a clearer
understanding of how sensory issues may be affecting a childs social and
emotional development.


What is the level of intensity of the childs emotional reactions?

What is the childs activity level?

When meeting new people, going to a new place, or trying

something new, what is the childs reaction?

How would you describe the childs moods? How long do they

What is the childs level of persistence when involved in an


How quickly does the child respond to changes in routine?

What is her level of attention span/attention to task?
How sensitive is the child to things in her environment?
How regular is this child about self-care skills, sleeping, eating,

Social interaction

What is the level of affect? (Does the face express a wide range of
emotions easily and freely?)



How does the child generally respond to his parents, peers,


What type of cues, if any, does the parent give to provoke a


Does the child initiate interactions with parents, peers, others?

What types of activities does the child engage in with parents,

peers, others?

How does the child separate from parents, familiar adults, familiar

Are the childs behaviors considered age-appropriate?

What is the childs awareness of others?

Does the child reciprocate in interactions with parents, peers,

Does the child have any anti-social behaviors?

What is the childs response to a group setting, activity?

Development as viewed through a sensory lens

We would now like to begin to set the stage for looking through a sensory lens
at child development, childrens behaviors, communication, and learning.
Again, this timeline is not rigid, rather it is reflective of the fact that each child
is unique. What is considered normal achievement of these milestones and
typical behavior can run the gamut. For example, a child may walk at 9
months or 15 months, a child may be very active or very quiet. These would
be considered as occurring within the normal range of development. While
knowledge of the developmental timeline may indicate potential developmental delays for a child, it may not necessarily red flag those more subtle
qualitative issues. Therefore, when we look at child development, the question
is not simply Can he do this? but How does he approach it and perform the
task?what is the quality of the performance? For example, a twoyear-old is expected to be able to run well without falling down frequently.
Now, how about the three-year-old that can run but the only way he can
turn or stop is to fall down, and the only way he can run is fast? Or how about



the three-year-old who is able to run but takes forever to cross the yard, with
arms flailing, who stumbles, but never actually falls?
Basically, the developmental timeline itself, though it gives a range for
milestones, will not necessarily reflect these qualitative differences in performance when assessing skill development. It is our opinion that the evaluators (parents, caregivers, daycare providers, teachers, or pediatricians) need to
be keenly aware of the quality of the skill that they are assessing. This is
critical for the child with sensory dysfunction. How about the two-year-olds
in the above paragraph who both ran without falling? If the evaluator is
going by the book, then they both get that skill checked off as achieved.
However, if the evaluator (parent, teacher, etc.) is looking at quality, the
picture changes considerably.
Now lets take a look at some scenarios using that sensory lens.

A five-month-old baby is able to drink from a bottle (skill

achieved). However, the bottle has three holes poked in the
nipple and it took the baby over an hour to drink 46 ounces. Is
this skill really achieved?

A 28-month-old toddler is saying two- and three-word phrases

(skill achieved). However, the words are less of an actual response,
and more of a parroting back of the last few words the other
person just used. Jillian, would you like a drink? Jillian responds
Like a drink. Is the skill really achieved?

A three-and-a-half-year-old boy is in his preschool program and

is observed to play in a variety of learning centers (skill achieved).
However, the child has been wandering around the room,
stopping to watch others play, never fully participating or
conversing. Is this skill really achieved?

A kindergartener is able to trace or print her first name

independently (skill achieved). However, her grasp alternates from
a mature to an immature grasp, she has a very light touch, the
letters are huge, with many letters formed from the bottom up. Is
the skill really achieved?

A 5th grader is observed to sit quietly and attend throughout the

mornings activities (skill achieved). However, the child was
slouching, slumping, sliding under the desk, constantly shifting in



his seat and is unable to answer content follow-up questions. Is

this skill really achieved?

An 8th grader is observed to get to class and get seated on time

(skill achieved). However, he arrives without his homework or a
working writing utensil, and he forgot his portion of the group
assignment that was supposed to be worked on that day. Is this
skill really achieved?

An 11th grader, who is characterized as charming, calm, and

compliant in the classroom; stressors appear to be within normal
rangeunder control (skill achieved). However, in anticipation
of changing classes, she becomes anxious, looking at the clock
frequently, breathing rate increasesanxiety is setting in! She is
waiting for the teacher to tell the class to pack up your gear, for
the bell to ring, and is straining to hear and copy down the
homework assignment. How is she going to get to her locker, the
bathroom, and maneuver through the noisy, crowded halls?she
actually feels sick just thinking about it. Is this skill really

What we are attempting to illustrate is that there are many different levels of
observation and interpretations of behaviors and skills. We are saying that
assessment of sensory dysfunction is the marriage of an art and a science.
There is a huge difference between an evaluator/observer who is competent,
and an evaluator/observer who is savvy and insightful, who is able to look
beyond the superficial attributes into the complexities of the assessment
process, and the uniqueness of every child. Looking back, we now see the difference between those who had the art down (tuned into the child, warm
and fuzzy, interactive with the family, genuinely caring), or those who had the
science down (great clinicians, superior mastery of the subject material,
current in their field, able to write a detailed report), and those who had both.
And, to be truthful, there were times when we needed warm and fuzzy, and
times when we really needed someone who would give us the cold, hard facts.
And then, there were the evaluators/observers who were able to combine the
art and the science to truly understand our children and their sensory issues
the challenging, and the unique as well as their individual areas of strengths
and weaknesses.

Chapter 2

What is Sensory Dysfunction?

Signs and symptoms

Now, lets take a look at what occurs when a portion of the process of sensory
integration is not functioning effectively and efficiently. It may show up in
learning, attention, coordination, activity level, developmental difficulties,
poor self-esteem, and behavior, but it will show up.
The following is a checklist of possible signs that a child may be experiencing difficulties with sensory integration. This is not meant to be inclusive,
but rather an overview of the more common indicators of possible sensory
integration dysfunction. The following information represents an expansion
of our initial understanding of the signs and symptoms of sensory dysfunction that appeared in Unlocking the Mysteries of Sensory Dysfunction (Anderson
and Emmons 1996).

Overly sensitive to touch, movement, sights, or sounds

Under-reactive to touch, movement, sights, or sounds
Activity level that is unusually high or unusually low
Difficulties with coordination
Delays in speech or language skills
Delays in motor skills (fine and/or gross)
Difficulties with academic achievement
Poor self-concept




Difficulties with executive functioning

Challenging behaviors

Overly sensitive to touch, movement, sights, or sounds

The child is easily overwhelmed by colors, textures, smells, sounds, or touch
(particularly unexpected or light touch). This may manifest as covering eyes
or ears, holding nose, gagging, vomiting, screaming, refusal to move (or could
seem frozen), or refusal to participate in certain movement activities (loves
the slide but hates the merry-go-round), or dislike of bathing, brushing (teeth,
hair), and other self-care activities.

Under-reactive to touch, movement, sights, or sounds

These are the children who may crash, jump, thump, whack things (people),
head butt, throw themselves, spin, rock, and generally seek means of sensory
stimulation. These are the kids who, if one sensory experience is removed, will
often quickly replace it with an equally intense sensory experience (e.g.,
four-year-old girl pedals a trike repeatedly into a brick wall, remove trike and
child begins to crash into other kids).

Activity level that is unusually high or unusually low

This is the child who is all over the place (high level of diffused energy) or the
child who is lethargic and everything appears to be a huge effort.

Difficulties with coordination

These are children who may be experiencing difficulties with fine motor
activities or gross motor activities, and often both. Frequently, balance is
impaired and motor planning is poor. It could be that the skills are present, but
the quality of those skills is of concern.

Delays in speech or language skills

Many people are unaware of the different components of speech, such as
receptive language, expressive language, pragmatics, articulation, fluency,
voice, oral/motor (see p.62 for an explanation of these terms). Delays may be
seen in one or more of these areas.



Delays in motor skills

Muscle tone, flexibility, quality of movement, safety with movement, fine
motor, handeye coordination, visual perception, personal care, and upper
extremity development may be delayed, diminished, or impaired.

Difficulties with academic achievement

A childs performance in one or more academic areas may, or may not, be truly
reflective of his or her ability.

Poor self-concept
According to Dr. Ayres, there are three things that can contribute to a negative
self-image: the way in which the nervous system is functioning, the feelings
of frustration and inadequacy that arise when a child cannot do things well
and other peoples negative reactions to what the child does (1979, p.161).

Difficulties with executive functioning

This is the child who appears to lack internal organizationmay be unable to
keep a neat desk, locker, or bedroom, has difficulty planning ahead and
having the things needed for an activity, basically disorganized and easily
confused, frequently needing assistance in order to bring tasks to completion.

Challenging behaviors
Challenging behaviors often include non-compliance, runners, hiders,
inflexibility, aggression, shut down, low frustration level, easily overwhelmed, low tolerance for the behaviors of others, low/high activity level,
physical proximity issues, perseveration (repetitive behaviors).

Dysfunction in the sensory systems

Now that you have a basic understanding of the mechanisms underlying the
sensory systems, as well as the basic five senses, we are artificially dividing the
sensory systems and their functions into separate categories in order to make
them easier to understand. However, please keep in mind that the systems
should work together simultaneously and cooperatively. In fact, if any one
system does not work properly either by itself, or in conjunction with the
others, it may result in a sensory dysfunction of some kind. The degree of
sensory dysfunction, whether it manifests as merely a sensory issue or mild,



moderate, or severe sensory dysfunction, is highly dependent on which senses

and/or sensory systems are impaired, and to what extent. We will talk more
about this a little later in this chapter, but please keep in mind as you read, that
it is the integration of these systems (along with the senses) that ends up
defining how we, as individuals, perceive the world around us and how this
translates into how we feel and behave. We will also take a look at how dysfunction in the sensory systems may translate into social issues and behavioral
difficulties and difficulty achieving age-appropriate skills development for a
child. Again, the sensory systems actually operate in conjunction and cooperation with one another, so the resultant behavior or sensation is probably the
outcome of accessing more than one system.

Dysfunction in the tactile system

A problem or inefficiency in the tactile system may manifest in a variety of
ways. A child may be tactilely defensive and not want to be touched, bumped,
or hugged, or to touch certain textures or wear certain types of clothes. An
atypical tactile system may also cause a child to crave certain tactile sensations and experiences: never able to keep hands to themselves, constantly
touching and feeling the people and/or things around them, absolutely
needing to have clothes feel (or not feel) a certain way. In other words, the
tactile system greatly influences relationships, fashion sense (clothing choice),
and school performance.

Dysfunction in the vestibular system

A problem or inefficiency in the vestibular system may cause difficulty with
balance, coordination, and motor planning. This may manifest as the child
who is clumsy and uncoordinated. This may be the child who strongly dislikes
gym days because she knows she is giving 110 percent, but struggles
anywaykickball, jump rope, etc. all require large amounts of motor
planning and appear to be fun for most of the other kids. How frustrating!
This may be the child who craves one type of vestibular input (swings), but is
very afraid of slides or bikes; or the child who is embarrassed because he
cannot even figure out how to get on a skateboard and ride for 30 seconds, let
alone learn the great tricks his friends are learning to do on their skateboards.
This may also be the child who is willing to ride the bus for hours (loves it!), or
the child who has a meltdown every morning at the bus stop. In other words,
the vestibular system will play a key role in the ability of a child to participate



successfully at sports, in gym class, on the playground, and in various activities

at school and at home.

Dysfunction in the proprioceptive system

This refers to an inefficiency in the proprioceptive system that may cause a
child to have difficulties both at school and at home. Since the proprioceptive
system gives feedback from the muscles and joints, it supports holding a pen
or pencil correctly, staying properly seated in a chair, applying the right
amount of pressure during a hug, or learning to use a knife, fork, and spoon
correctly. This system also supports learning to walk, opening and closing jars
and doors, using playground equipment and chewing!

Logans day
Now we would like to help make all of this academic information come
alive. One of the most challenging aspects of sensory integration dysfunction is learning how to identify and tease apart the components of the underlying dysfunction. While each child is unique and sensory problems vary
greatly in both type and degree, this section will give you a clearer idea and
better understanding of the day in the life of one child with sensory dysfunction. The following is an example of some of the experiences, challenges, and
interactions of a 3rd grade boy named Logan, who has sensory dysfunction.
Logan wakes up, is chilly because he took off pajama shirt in
middle of night because tag bothered him (tactile). Gets out of bed and heads
to bathroom. Bumps into doorframe on the way out the bedroom door (vestibular/proprioceptive). Uses toilet, refuses to flushnoise bothers him (auditory
defensiveness). Has difficulty turning on faucet (proprioceptive), can tolerate only
cold water (tactile) and forgets to use towel to dry handsdont feel wet.
Heads downstairs to eat and watch video.
Stumbles on steps, but does not fall (proprioceptive/vestibular).
Goes into kitchen and pulls out pre-prepared breakfast (Mom and Dad want
to sleep until 6:30!). Logan will only eat a peanut butter and strawberry jam
sandwich and a glass of Welchs grape juice for breakfast (gustatory), he refuses
cereal because he cannot stand crunchy food (texture/auditory).
Eight-year-old sister comes downstairs, tells Logan to wipe the
jam and grape juice off of his face and chestLogan did not realize he had



spilled food on himself (tactile/proprioceptive). Logan bumps into sister when

getting towel (vestibular/visual). Yells at sister for being in his way.
Mom comes downstairs and asks Logan to get dressed and to
brush his teeth. Logan protests, but stomps upstairs (proprioceptive). Logan
cannot find his shirtwhich is on the top of his dresser next to his baseball
glove (visual). Logan gets himself dressed (proprioceptive/visual/vestibular/
Heads to bathroom to brush teeth. Squeezes too much toothpaste
(visual/proprioceptive). Brushes teeth, gagging on taste of toothpaste (gustatory).
Logan heads back downstairs to watch favorite video. Logan
clumsily shoves the video into the VCR (proprioceptive/tactile) and sits mesmerized by the video he has seen at least 100 times. The sound is too loud and
Mom tells Logan to turn it down a couple of notches (auditory).
Mom tells Logan to turn off the video, it is time to get ready for
school. After one more warning, Logan turns off the video, grabs his knapsack
and goes out to wait in the car.
Mom hands Logan his jacket and demands that Logan put it
onit is 38 degrees outside! Logan protests, saying that he is not cold and
refuses to wear that jacket because he cant stand the sound of nylon when it
shooshesit creeps him out (tactile/temperature/auditory). Mom runs in and
retrieves Logans fleece jacket, because they are going to be late and she
knows that Logan will probably not be able to find his jacket hanging in the
closet with all of the other coats and jacketseven if it is right in front of him
Logan and his sister are dropped off at school. Logan walks while
covering his ears because he knows that the first bell will ring at 7:58am
(auditory). Logan jostles through the throng of children, heading up the stairs
to his classroom. He arrives angry because he is positive that several other
children intentionally bumped him as he ascended the stairs (tactile, proprioceptive).
Logan takes off his jacket and hangs up his knapsack, then sits at
his desk, knocking over Sarahs chair on his way through the room. Sarah



sighs in exasperation, but Logan doesnt seem to notice the sigh or the fact
that he knocked over her chair (visual/tactile/auditory).
Mrs. Miller asks Logan to take attendance and lunch count down
to the office. Logan accidentally walks into the classroom next to the office
(visual). Stumbles once on the steps on the way back up to his classroomstupid steps! (proprioceptive/vestibular)
Mrs. Miller asks the class to take out their math books and
homework. Logan fumbles through his desk, finding everything but a
pencilits in there somewhere, but feeling around for it inside the desk is
hard! (discriminatory touch).
Mrs. Miller hands out a small package of M&Ms to each student,
instructing the class to open the package carefully (the class will be learning
about fractions today!). Logan (and one other boy) somehow rips open his
package with too much force and M&Ms spill all over, under, and around his
desk (proprioceptive).
Mrs. Miller instructs the class to line up for gym. Logan arrives at
gym a little agitated because Robert kept bumping into me on purpose
(proprioceptive/visual)Robert and the rest of the class agree that it was Logan
who stopped suddenly and was not watching where he was going.
Mr. Rodes quickly prepares his class for a game of soccer. Once
the game begins, Logan alternately stands with his hands over his ears or yells
at the top of his lungs (auditory). There is too much movement (visual) and
noise (auditory), Logan is overwhelmed (sensory overload) and begins to
meltdown, crying and yelling.
Mrs. Miller tells the class to get into their assigned groups and
work on their social studies project. Logan becomes agitated as the noise level
of the room rises (auditory), he speaks loudly and almost knocks over the
diorama! (visual).
11:45am The children go to the cafeteria for lunch. Logan sits with his
classmates at their assigned table. Throughout lunch, Logan slides off the
bench (proprioceptive), stuffing his lunch into his mouth (proprioceptive/tactile).
Logan always has the same lunch (texture/gustatory), and gags if he smells tuna
fish (olfactory).



12:15pm The children go from the cafeteria to the playground for recess.
Logan runs to the swing and spends the entire recess swingingas he does
every day (vestibular).
12:45pm The children go back to the classroom and sit quietly while Mrs.
Miller reads a book aloud. Logan rocks gently in his seat while listening
intently (vestibular/proprioceptive).
Mrs. Miller instructs the class to line up for art. Logan complains
loudly that he hates artthe room smells awful (olfactory), and he hates
touching the weird paper, paints, and brushes (tactile).
The whole school gets ready for dismissal. Logan hurries past the
buses because they are too loud (auditory) and smell just awful (olfactory),
looking for his babysitters car. Janet, the sitter, tries to park in approximately
the same place every day, because she knows that Logan has a hard time
finding her car amid a line of cars (visual). If he cant find her, he will panic.
Logan eats his usual snack of raisins, a cheese stick, and a Welchs
grape juice box. He usually has difficulty opening the cheese stick and
unwrapping the straw for the juice box (proprioceptive). Logan and his sister
and playmates go outside to play. Logan usually swings by himself, he hates
the slide and isnt very good at catch (vestibular/visual). The other kids dont
like to play tag with Logan because he pushes too hard when he tags them
Dad arrives to take Logan and his sister home. Logan requests a
bear hug (proprioceptive/tactile).
Logan works on homework while Dad starts dinner. Mom walks
in the door just as Logan starts to rip his homework paper. Logan tearfully
screams, I can never get the stupid numbers to line up, so my answer is always
wrong! (visual).
Dad calls everyone to the dinner table. Logan runs to the table,
stubbing his toes on his chair (vestibular). Logan grumbles as Mom hands him
his plate of macaroni and cheese, peas, carrots, and apple sauce. Logan wont
eat the apple sauceits too chunky (texture) and Mom forgot to scrape the
breadcrumbs off of his macaroni and cheese (way too crunchy) (texture).



Logan leaves the kitchen covering his ears because the noise of the
dishes clattering bothers him immensely (auditory).
Logan goes to karate class. Logan loves being in his bare feet on
the hard floor (texture/proprioceptive) and being able to chi up (yell) loudly
(auditory). This form of karate, suh bahk do, is non-contact so he doesnt have to
worry about touching people too hard (like in games of tag).
Mom tells Logan to get ready for his shower. Logan gets the water
just the way he likes itMom says its so cold, she thinks Logan is part
penguin (tactile/temperature). Sometimes Logan forgets to rinse his hair or to
towel off after showeringhe just doesnt feel the shampoo on his head, or
the water dripping from his body (proprioceptive/texture).
Mom and Dad tuck Logan into bed, but Logan wont be able to
sleep because his bed has the scratchy sheets. Mom and Dad realize that
Logan will be up and unable to sleep, so they quickly change his sheets to the
soft, comfortable ones he likes (texture).
Mom and Dad hear Logan rhythmically rocking back and forth in
his bed (vestibular/proprioceptive).

Logan falls asleep.


Logan awakens and needs help falling back to sleep.

Keep in mind that no child (or adult) has perfectly integrated sensory systems
all of the time. Sensory issues will vary within any child throughout the day,
depending on specific environmental circumstances and physiological state.
Certainly, feeling tired, hungry, or sick will greatly affect how our sensory
systems work and how our brain interprets the incoming information from
our sensory systems. Growth spurts and hormones also affect the way a childs
body responds to sensory input. However, a child who has sensory integration dysfunction will have relatively specific and predictable sensory issues,
while it may not appear so initially. Notice that Logan was very sensitive to
loud noises (auditory sensitivity) that he could not control, but if he was the one
in control of the noise, loud was fine. Also, certain textures were an issue
throughout the day, as were specific temperatures and taste aversions/preferences. It is also important to note here that certain activities involving specific
sensory systems were either craved in an obsessive manner (swingingvestibular) or avoided at all costs.



Sensory dysfunction through the developmental stages

Now, lets explore the different stages of life, newborn through school age
and beyond, and how sensory integration dysfunction may present. For the
purposes of this book, we are describing a wide range of behaviors and
symptoms that may indicate some level of sensory dysfunction. These lists are
not meant to be used for diagnostic purposes, rather to create a greater awareness of some of the sensory difficulties a child may experience over the course
of development.

Newborn to age one year

Typically, most bets are off when it comes to diagnosing a child at this early
stage. However, in a retrospective kind of a way, first-year behaviors and
developmental milestones become quite germane when assessing the developmental history of a child for sensory dysfunction. Please keep in mind that
most babies will present with one or more of these characteristics for a (relatively) short period of time. The basic difference is that a typical baby will
gradually become more self-regulatoryeating, sleeping, playing, and
crying within reasonable (and tolerable) limitscolicky babies eventually
stop being so intensely fussy and irritable, the sensitive baby who startled at
every little noise stops being so jumpy as her/his nervous system matures.
An infant who has sensory dysfunction probably did not pass through the
more difficult phases with a gradual ease. In fact, chances are quite good that
such an infant was a difficult or different baby, who somehow remained
intense and difficult throughout the first year of life.

Chronic crying
Almost never cries
Inability to develop a reasonable sleep pattern
sleeps too much
only sleeps for very short periods of time (power naps)

Dislikes being swaddled

Only likes a certain texture or material close to skin
Overwhelmed by relatively low amounts of noise



Appears to be oblivious to noise, even loud noises

Fine motor milestones are late or have not occurred yet, e.g.,
sucking independently, holding bottle or cup, tracking faces and
objects, grasping objects with hands, attempting to pull off socks,
hat, bib

Continued, intense reaction (vomiting, screaming) to certain

textures or tastes of food or drink

Craves certain smells

Very aversive to certain sensory input: swinging, sliding, jumping,


Nothing seems to startle him

Everything seems to startle him
Dislikes being touched or held
Demands to be held or touched constantly
Bare feet not able to tolerate the texture of carpet, bare floor, etc.
Gross motor milestones are late or have not yet occurred, e.g.,
rolling from tummy to back and from back to tummy, sitting up
unsupported, grabbing for rattle or toy, creeping, army crawling
or crawling

Very aversive to certain smells

Craves certain sensory input: swinging, sliding, jumping,



Is not particularly interested in faces

Poor or intermittent eye contact

Is not particularly interested in social games (peek-a-boo, smiling,

silly faces)

Does not babble

Unable to be comforted (rocking, singing, walking, swinging)


Much more interested in objects (or parts of objects) than in


Acts as if deaf


Constantly jabbers
Will only play with one or two specific toysalways in the
same manner (e.g., only interested in clapping blocks together or
pressing the button on a toy or watching things spin)


Does the infant need to be held, walked, or rocked all day? Or does the infant
scream when being picked up, rocked, or riding in the car? Does he calm
when touched, stroked, or massaged? Or does she scream when being held,
having a diaper changed, or being dressed? Does the infant respond to bright
colors, bright lights? Or is he under-responsive or looks away from them?
Does the infant seem unbothered by sudden loud noises? Or does she scream,
become frantic, or become rigid when the doorbell rings, someone knocks on
the door, the telephone rings, or you turn on an appliance? Some infants, for
example, will nurse or drink a bottle without event; while others may have a
sucking reflex described by one mother as like a Hoover vacuum on high or
may take hours to nurse or drink from the bottle. Some infants take 20-minute
power naps throughout the day (never connecting two hours of sleep). Or
they sleep anywhere, anytime for extended periods of time on a fairly regular
Most parents and pediatricians agree that many of the behaviors seen in
babies tend to be ephemeral and only become diagnostic when viewed
through the lens of time. There are exceptions to this, of course. For example
when a baby has a physical problem such as prematurity, an infection, a
hernia, deafness, or blindness, which makes him fussy, irritable, or unable to
process sensory stimuli. Pediatricians are trained to rule out such physical illnesses and ailments in infants. In most cases, however, after the appropriate
medical screening, parents are told to relax, and that their baby is simply
going through a difficult phase, or is a very sensitive baby.

The toddler
Most toddlers are tumultuous and terrific, changing gears seamlessly and frequently. Toddlerhood is a time of explosive physical, cognitive, social, and



emotional growth. The child who was a helpless infant only 18 months ago, is
now attempting to climb up onto the kitchen counter and explore the sink!
The world is calling to the toddler, and the toddler is eager to respond.
Again, in retrospect, the signs of sensory integration dysfunction are often
evident during toddlerhood. However, the typical toddler has many transient behaviors, which will most likely wax and wane, but will eventually
regulate themselves over time. Again, the typical toddler will transition into
a preschooler, who is much more mature (comparatively) and who has an
improved ability to self-regulate. The toddler who has sensory integration
dysfunction will most likely present with behaviors that remain quite
toddler-like as she ages into a preschooler. The play of a toddler who has
sensory integration dysfunction is usually qualitatively very different from his
typical counterpart. This is also the time when the characteristically uneven
skills of the child who has sensory integration dysfunction often become
much more noticeable.

Tantrums frequently and intensely (constant sensory overload)

Aversive to certain sensory stimulation (sounds, textures, smells,


Inability to develop a reasonable sleep pattern

Craves certain sensory stimulation (sounds, textures, smells,


may have very irregular or disjointed sleeping patterns

may wake up at same time each morning regardless of the
time she goes to bed the night before

Loves/hates certain sounds (toilet flushing, coins dropping,

vacuum cleaner, etc.)

Very sensitive to sounds or crowds

Aversive to being touched or held
Constantly has hands all over everything or everyone
Craves certain sensory input: swinging, sliding, jumping,


Aversive to certain sensory input: swinging, sliding, jumping,


Continued, intense reactions (screaming, vomiting) to certain

textures or tastes of specific foods or drink

Appears so engrossed in activity of the moment that she seems

unaware of the people or activity around her

Delays/difficulties in gross motor skills


Not playing with toys that require fine motor manipulation

Not feeding self easily or well
no orientation to spoon or cup



More interested in adults than other children

Unusually distractible

Insists on routine, or tantrums and melts down

Monotone or sing-song voice

Limited interest in faces

Limited social game playing (peek-a-boo, smiling, silly game

Intense powers of concentration for certain activities

May not point, or only points infrequently
Talks incessantly/rarely
Poor or intermittent eye contact
More uncomfortable in new situations for a longer period of time
than would be expected

Flat affect (face does not express a wide range of emotions easily
or freelypoker face)



Will only play with a very few selected toysalways in the same
manner (spinning wheels on cars, pressing buttons, dumping
blocks, listening to vacuum cleaner or other motors)

Intensely interested in one subject to the exclusion of virtually all

other subjects (construction equipment, a specific cartoon
character, specific book, or specific species of animal)

Most parents will only recognize these symptoms in hindsight and seek
help for their child when the child becomes older and the characteristics are
persistent or intensified. Frequently, however, parents will feel uneasy about
their childs development and perhaps seek professional advice, only to be
told to wait it out. Often parents are told that things (i.e., behaviors) will
improve as the child grows and becomes more emotionally mature and more
socialized. The advice typically given to the parent is to have the child join
a playgroup and to keep introducing new experiences gradually, but

The preschooler
The typical preschool child is fun-loving, inquisitive, and social. Preschoolers
are raring to experience new sights, sounds, and situations (as long as a trusted
adult is in sight). Preschoolers are able to walk, talk, argue, and think independently, they begin to play cooperatively with their peers, and make their
opinions known to all! Most three- and four-year-olds love to laugh and learn
new things and have begun to understand many complex social rules and
many of the rules of language (pragmatics of language). It is at this age that
many parents of a child with sensory processing difficulties become even
more confused, because those odd qualities in their child that were
supposed to fade are often still present, or even amplified.

Unusually anxious
High tolerance of pain
Low tolerance of pain
Still has not developed a reasonable sleep pattern (too much or
too little)


May wake up at same time every morning, regardless of bedtime

the previous night

Tags/clothing/textures bother him


Very picky eater

certain textures/tastes/temperatures of food are aversive or
does not know when he is full
vomits or gags easily (does not tolerate certain foods well)

Very sensitive to noise around him

May act oblivious to noise or confusion surrounding him
Craves or has aversions to certain physical activities
proprioceptive: jumping, stairs, hopping, lifting heavy things
vestibular: swinging, spinning, rocking, sliding
tactile: hates to be touched, or has hands all over everyone
and everything, insists on certain textures

Persistent drooling

Chewershirts, blankets, toys

Clumsy with balance and coordination: difficulty riding and using

age-appropriate toys (big wheel, trike, pull toys, tracking balls,
kicking balls)

Lack of hand dominance

Hypotonic (poor posture)

Strong preferences for or aversions to specific playground


Clumsy with fine motor activities: eating, drinking, using writing


Difficulty crossing midline (the imaginary vertical line that divides

the body in two): for example, using the right hand to reach an
object on the left of the midline

Difficulty with bilateral coordination

Falls out of chairs



Prefers adults to children

May only play with a very few selected toysalways in the same
manner (spinning wheels on cars, pressing buttons, dumping
blocks, listening to vacuum cleaner or other motors)

Limited interest in playing with toys outside of his area of interest

Prefers to play with much younger children, or by self

Voice modulation issues (consistently too loud or too quiet)
Monotone or sing-song voice
Strange rhythm to speech
Asks constant questions, but may not wait and listen to response
Poor or intermittent eye contact
Emotionally labile (laughing one minute, crying the next)
Perseverative (repeating behaviors)
Socially aloof with peers/socially intense
Rarely or never points
Easily overwhelmed
Strange quality to play with other children
Inflexible; insistent on routinemay become frantic if routine is

Intensely interested in one subject area to the exclusion of

virtually all other subjects (construction equipment, a specific
cartoon character, specific book or specific species of animal)

As the preschooler ages, strange proclivities and odd behaviors may begin to
really stand out. Often, because the child with sensory integration dysfunction has unevenness of skill development, parents, grandparents, caregivers,
preschool teachers, and pediatricians may be apt to downplay the childs
weaknesses and focus primarily on the childs strengths.

The school-aged child

Now is when, as the saying goes, the rubber meets the road. The child with
sensory integration dysfunction may remain on that border of being consid-



ered a bit odd, but still within the realm of normal, or, most likely, will cross
over into the realm of displaying some (a few, many) problematic behaviors.
Often the child with sensory integration dysfunction will be categorized as
immature and, possibly, spoiled.
The new social, cognitive, and motor demands of the school setting often
create even more confusion, anxiety, and chaos for the child who has sensory
integration dysfunction. Remember, all the sensory systems need to be
working well cooperatively for higher skills acquisition and performance! All
too often, the only way the child has of dealing with this environment is to
space out, act out, and become more rigid, inflexible, anxious, and socially challenged!

Over/under-sensitive to pain

Unable to focuseyes and attention are all over the place

Is aversive to sight, smell, or taste of certain foods

Unable to tolerate certain types of clothing or tags, or the sounds

certain clothing makes (e.g., nylon rubbing on nylon)

Is clumsytendency to bump, trip, bang into things

Over/under-sensitive to temperature
Shouts or whispers most of the time
Becomes wild or confused and lost during recess
Certain noises bother her to an extreme degree
May have difficulty keeping hands to herself
Constantly touching other students or objects
May complain frequently of being bumped and touched by other

Slides out of seat easily, attempts to lie down or sprawl, frequently

slumped over desklooks like a rag doll at times

Acts grossed out or may gag when touches certain textures

(paint, glue, sand)

Difficulty prioritizing sensory stimuli



Executive functioning issues emerge or become amplified

Need for higher level of adult supervision for a variety of reasons

(management, social, academic, organizational)

The lethargic student

Diminished strength and endurance

Social skills deficits may become more obvious

Behavioral immaturity
Unusually picky eater
Difficulty during lunchmanaging time, opening container
independently, messy eaters, meticulous eaters

Identification of learning disabilities
Visual-motor difficulties
Distorted sense of weight (a light bag of groceries may feel very

Over-dressing or under-dressing for the weather

Pronounced trouble with changes in routines or plans
Difficulty making choices when confronted with several options
Falls apart easily over seemingly minor occurrences
Articulation problems
Oral/motor issues (needs to chew all the time, drools, or hates to
brush teeth, may loathe going to the dentist)

Often, at this point, the child with significant sensory issues may become
more frustrated with himself and more challenging to those around her.

The functional areas as viewed through a sensory lens

Now that we have looked at the developmental timeline and its sub-categories
(cognitive, language and communication, motor (including vision and



hearing), social/emotional, and adaptive), we have established that sensory

integration is a component embedded within all domains. We suggest that in
assessing each sub-category, it is critical to identify the sensory components
within skill development.

Delay or disability in cognitive development

The child demonstrates deficits in intellectual abilities beyond normal variations for age and cultural background. These difficulties might be in ability to
acquire information, problem solving, reasoning, generalizing of information,
rate of learning, processing difficulties, memory delays, and attention or
organizational skills.
What might this look like in the child with sensory integration dysfunction? In our view, it is very difficult to tease apart the sensory component in
cognitive development. For our purposes here, we are going to consider cognitive development (not strictly IQ ) as a combination of the acquisition and
mastery of communication, memory, and adaptive skills development.

Delay or disability in language and communication

The child demonstrates deficits beyond normal variation for age and cultural
background that adversely affect the ability to learn and acquire skills in the
primary language. These difficulties might be in receptive language, expressive language, articulation/phonology, pragmatics, fluency, oral/motor skills
or voice (sound quality, breath support).
What might this look like in the child with sensory integration dysfunction? A baby with sensory issues in the area of language and communication

take a long time to respond (or doesnt respond) even to a familiar


need his name called several times before responding

give poor or little eye contact

scream at unexpected noises, crowded places, or just when alone

(screaming is his only way to tell you something is not right in
his world)

not be interested in faces

not attempt to imitate sounds (babbling).



A toddler with sensory issues in the area of language and communication may:

have a very flat affect (not beginning to show a wide range of

expressions: happy, sad, surprised, puzzled)

sometimes act as deaf, even though hearing tests out as normal

have difficulty following simple directions

tantrum frequently and intensely.

continue to chew and eat non-edibles

stuff her mouth with food, gag, choke on a regular basis
continue to drool copiously
rely on screaming, gesturing, vocalizing to communicate

have difficulty pointing to or naming common objects when


The preschooler with sensory issues in the area of language and communication may:

have difficulty responding appropriately to what is heard

have difficulty responding to the comments and questions from


have difficulty answering simple questions/asking simple


be difficult to understand when speaking

have difficulty following one-step directions (group setting) and

two-step directions (individually)

have tantrums that are frequent and/or intense.

Delay or disability in adaptive development

The child demonstrates difficulty in learning or acquiring the skills necessary
for daily living and learning through play. These occur over time, in a variety
of situations, and interfere with the effectiveness of the childs ability to meet
personal needs, social responsibility, or participation in developmentally
appropriate situations and cultural group.



What might this look like in the child with sensory integration dysfunction? A baby/toddler or preschooler with sensory issues in the area of
adaptive development may:

not like being cuddled

have difficulty sensing, or overly sense the urge to urinate or


become agitated when being bathed (hair washed, face wiped)

not be developing age-appropriate play skills

be under/over-reactive to pain.

over-react/under-react to changes in temperature and textures

over-react or under-react if hands, face, clothing and/or diapers
(excessively soiled underpants in older children) are messy

have poor body awareness and/or poor motor planning as seen in

difficulties with self-dressing, feeding, and other adaptive

have difficulty in many functional areas out in the community

(shopping, visiting relatives/friends, playgroups, childrens
museums, libraries, etc.)

Beyond the age of five, children typically become much better at compensating for their sensory issues because they have such a strong desire to fit in
with their peers, so the adult must look even more closely at the behaviors of
the child who may:

continue to be over-reactive/under-reactive to changes in textures

and temperatures

continue to avoid self-care activities (bathing, combing hair,

washing face, clipping nails, dressing, teeth brushing, flossing,
shaving, feminine care issues)

have difficulty sensing, or overly sense the urge to urinate or


continue to be under/over-reactive to pain

continue to have poor body awareness and motor planning.



Delay or disability in social/emotional development

The child demonstrates deviations in affect or relational skills beyond normal
variation for age and cultural background. Problems are exhibited over time,
in various circumstances, and adversely affect the childs development of
age-appropriate skills.
It is our opinion that the evaluator from each discipline should consider
making note of and including the social/emotional elements during assessment. This could be included in the narrative portion of the evaluation, and
may provide some of the most valuable information regarding the childs level
of sensory processing and sensory dysfunction.
What might this look like in the child with sensory integration dysfunction? Typically, this will be seen as problems with:

greeting others
play with peers
role in a dyad
ability to handle conflict
attention span
responses to request
awareness of self/others
social participation.

Delay or disability in motor development

The child demonstrates a deficit beyond normal variability for age and experience in coordination, movement patterns, quality or range of motion, or
strength and endurance of gross (large muscle), fine (small muscle) or perceptual motor (integration of sensory and motor) abilities that adversely affects
the childs ability to learn and acquire skills. These skills may include main-



taining and controlling posture, functional mobility (walking, running),

sensory awareness of the body or movement, overall sensory integration,
reach and grasp of objects, tool use, perceptual motor abilities (eyehand
coordination for tracing), and sequencing motor components to achieve a
functional goal.

Assessment and evaluation

Becoming a sensory detective
People often ask, What constitutes sensory integration dysfunction or a
sensory processing disorder? When do we know the child has sensory integration dysfunction? What is the difference between a sensory issue and
sensory dysfunction? These are good questions and this remains a somewhat
complicated issue. First of all, sensory integration dysfunction by itself is not a
clinical diagnosis, according to the DSM-IV (American Psychiatric
Association 2000). Which, translated, means that there are no blood tests or
biological markers, so basically it requires a health professional (usually an
occupational therapist or a physical therapist) working from an observational
checklist marking off specific indicators under specific categories. Second, the
term sensory integration dysfunction is often used interchangeably with
sensory dysfunction and sensory processing disorder, making things confusing at times. And frequently sensory integration dysfunction is concurrent
with diagnoses such as autism spectrum disorder, cerebral palsy, Down
syndrome, ADHD, learning disabilities, etc. However, it has been our experience as teachers (special education and general education) that sensory integration dysfunction is most often a co-condition with another diagnosis.
Only rarely have we encountered a child with a straight diagnosis of only
sensory integration dysfunction.
Again, it is our belief that there is significant difference between sensory
integration dysfunction and a mild sensory issue. For us the bottom line is:
Are the sensory difficulties impacting daily living, relationships, learning,
and behavior; and, if so, to what degree? Here is where we need to talk about
degree and quality. Now, for a four-year-old who is exhibiting typical
behavior in every other area but refuses to put her hands in the sandbox, is this
really a big problem? Is it really pervasive? Is it really adversely impacting her
life? Could it be that this is just a stage or something ephemeral? In other
words, will she grow out of this? And, does it really matter if she does? (There
are plenty of adults who do not like to get their hands dirty.) However, if she



doesnt like to put her hands in the sandbox, and gags when she touches glue
or finger paint, and falls out her chair, and the slide terrifies her, and her mother
has intense daily power struggles with her about what she is going to wear
and what she is going to eat, and is obviously overwhelmed by large group
activities, now do we have a big problem? Is it pervasive? Is it impacting her
life/learning/social development? Maybe. At this point, as parents and as
teachers, we would want to take a closer look at this childs level of previous
experience and exposure to these types of activities. If lack of exposure and
experience can be ruled out as a strong contributing factor, then we would
recommend to this childs parent that she receive further evaluation while at
the same time begin to kick into gear some sensory-based strategies to help
this childs individual needs.

Gathering and documenting information

If, as a parent or a teacher, you suspect that a child (or your child) has significant sensory issues or sensory integration dysfunction, you now become the
detective. Now is the time to start documenting your dealings with the inevitably complicated array of service providers, and gathering information that
will be useful for a professional assessment.
Okay, now that you have got your detective hat on, what you are going to
need is some time and a focus. Next up is a notebook; decide what will go into
that notebook, and start thinking who you might share it with. As parents, we
found it useful to write down the dates, phone numbers, and a brief, general
description of whom we spoke to and about what.
Heres an excerpt from Pollys first notebook:

Called Carol (Initial Service Coordinator from Early Intervention
Agency). Not in today, left message, will call back tomorrow.
Called Sue (speech therapist) regarding evaluation comments on
Dylans echolalia. States that it is found predominantly in autistic
children. Asked if I would agree to a Psychological. I asked directly
if he would receive speech services. Sue advises no, but he would
be evaluated at regular intervals.



Carol calls back. States she will contact Mary (Committee on Preschool Education Chair) regarding Dylans speech services and
aging out of preschool special education services. Carol said she will
contact Robin (Physical Therapist Evaluator) and see if she has
enough concerns to recommend that Dylan receive physical therapy
services. Carol calls back in the afternoon saying that she spoke with
Mary (CPSE Chair) and that Dylan will not receive any summer
services or services next year unless he is enrolled in Kindergarten.
Called Barbara to verify this information (is this true?). Barbara
states that if Dylan is recommended and approved for a 12-month
program, CPSE must provide services through August.
This example is really from Pollys first notebook. She was a concerned mom
who was struggling to understand what was going on, and the rules and the
regulations, and just wasnt always getting consistent information. This may
not be what an excerpt from your notebook will look like, but it gives you an
idea of how important it is to document times, dates, people and information
so that it can be referred back toeven years later. Can you believe that this
speech therapist would throw out that a child she just evaluated may have
autism, recommends a psychological evaluation, and does not initially recommend speech services? Honestly, as it turned out, some of Dylans and Ellies
best allies have been some incredibly committed and compassionate therapists
and Sue, this speech therapist, was eventually one of them.
In addition to documenting communications and conversations, you will
want to start documenting behaviors. It is imperative to note the specifics of
the behavior: What does it look like? How long did it last? How often does it
happen? And where does it happen? For instance, mentally you may have kept
track that every time you walk into a grocery store with your child he has a
super-sized meltdown. So, now you want to actually look at the behaviors
and write down what the meltdown looks like Johnny is smiling and
happy entering the store, but once he gets near the carts he starts pulling his
hand away from yours and starts screaming. You have learned that you cannot
physically force him into the front seat of the cart, but if you hoist him into the
back of the cart he spends about a minute and a half thumping his feet against
the bottom of the cart and then stops screaminggravitational insecurity
(anxiety caused by, for example, feet leaving the ground, movement and
heights)? We dont know, but it is worth keeping track of. Now that you think



about it, he melts down getting him into his car seat too (which looks like
arching his back, screaming no, no, no and pushing you away with all of his
might). Is there a connection? We dont know, but its worth keeping track of.
And now after the grocery shopping, Johnny is being dropped off at preschool and you are his teacher. Initially, you may assume that Johnny is being
difficult because his mother usually looks stressed out and you figure that
they had a tough morning. Mentally, you have kept track that Johnny has difficulty sitting, attending and on the playground. But when you begin to write
the behaviors down, you are surprised to see a pattern developing. Johnny
never has difficulty at circle time (sitting on the floor), but he screams and
thumps his feet when he sits at the chairs at the art table (the taller chairs)
intermittently until the activity is over. And while Johnny loves to run around
on the playground, he refuses to go anywhere near a swinggravitational
insecurity? We dont know but it is worth keeping track of.
Now when Johnnys parents and teacher have a parentteacher conference, both parties can now share specific and well-documented concerns with
observations and examples. Writing down observations serves valuable
purposes for both parents and teachersand most importantly for the child.
The communication log for the parent then may reflect:

Met with Johnnys teacher, Ms.Taylor, for a parent conference. We
shared our concerns about Johnnys behavior at the grocery store
(screams, refuses to sit in front of cart, thumps feet in back of cart)
and in the car (screaming, non-compliance) and that these behaviors
seem to occur when he is forced to take his feet off the ground. Ms.
Taylor shared that Johnnys behavior at school is more challenging
(screams and thumps feet) when he sits in the taller chairs and that he
also refuses to go on the swing.
Here are just a few ideas to get you started taking a closer look at possible
sensory-based behaviors. Lets begin by having you answer the following

How does this child respond to

being touched by others, touching others?
different types of clothing?
different textures?



activities that involve self-care (brushing teeth, washing,

bathing, hair combing, nail clipping, shaving, feminine care)?
different types of foods (temperature, taste, texture,
having his feet off the ground?
having his head upside down during play or sports?
different types of movement activities?
his surrounding environment (people, things, noises, smells,
visual stimulation, etc.)?

What is your childs attention span?

How does he respond to being around other people?

Physicallydoes he tire easily, or never slow down?

What is his choice of physical activities? Activities that involve
grasping and/or manipulating objects?

How does he respond to changes in routine?

Childhood development experts seem to agree that the earlier the identification and intervention for sensory integration dysfunction is begun, the better.
If we know that the first few years of life are the most important time for brain
development for a typically developing child, then we know that these years
are critical for a child with atypical development. Some disabilities will be
detected either immediately or shortly after birth, other will take a few weeks.
However, while sensory integration dysfunction is apparent early on, it often
goes undetected for months or years. It is not uncommon for a child with
sensory integration dysfunction to reach preschool age or even school age
before being identified. How can this be?
Unfortunately the identification of children with sensory integration dysfunction most often depends on the knowledge and experience of the adults
in their lives. There will be children who have a diagnosis where the sensory
piece is either underestimated or overlooked. Other children who may be
exhibiting the behaviors and symptoms commonly associated with sensory
integration dysfunction may get the wait and see approach or be missed
altogether. Some of these children may meet the criteria of another diagnosis,
possibly an autism spectrum disorder; others may not (see Chapter 3).



The role of assessment

The role of the assessment process is critical to beginning to target the needs
of the child. We believe that early and accurate identification of any need is
essential in order to give the child the potential for best possible outcome.
And it is our belief and experience that many times it is the sensory component (to whatever degree) that is overlooked or undervalued. That having
been said, we want to recognize that the assessment process can have many
drawbackscultural bias, artificial setting, purposeless tasksand is sometimes used for purposes for which it was not intended. In addition, we also
want to recognize that there can be the over-representation and under-representation of certain racial and ethnic groups in special education. However,
this is the system that is currently used and we must work within it as we work
to improve upon it.
In general, whether done formally or informally, the purpose of assessment is to take a closer look at a childs development in five areas: cognitive
(learning) skills, language and communication skills, motor skills (including
vision and hearing), social/emotional skills, and adaptive skills. There are
many different ways to assess children, just as there is a wide variety of assessment tools available. Assessment can be formal, using standardized testing, or
informal, making use of observation using checklists, rating scales, etc. Assessment may be done informally simply to note progress over time in an area of
skill development. Or assessment may be done formally to determine if the
skill levels are deficient enough in any one area, or combination of areas, to
warrant further investigation.
The assessment process can be broken down into logical steps. What we
want to do is to highlight the tremendous importance of each step in the

Identifying a possible need will determine which, if any,

evaluations should be performed (pediatrician referral, parents,

Evaluations, if any, will assess the need and determine whether

any additional evaluations are warranted. For example, the parents
make a referral because they have concerns about their childs
speech. The speech therapist evaluates the child. Now is the time
for the speech therapist, or any other initial evaluator, to look
beyond his or her specific discipline at the whole child to determine
if any other needs, sensory or otherwise, exist and to make the



recommendation for any supplemental evaluation. Often, this is a

matter of professional awareness and judgment.

The assessment(s)/evaluation(s) will help determine which, if any,

interventions are needed.

The level of intervention needed will help determine which

services, if any, should be provided.

The services, if any, will help determine a childs program.

A program will help determine how the childs needs will be met
through, for example, related services, curricular adaptations,
environmental modifications, management needs, teacher training,

It all starts with the identification of a childs need and the assessment of this
need. It is our belief that the sensory piece, if any, needs to be identified and
assessed as early as possible to ensure that it is incorporated into any intervention, service, or program.
Traditionally, sensory integration has been the exclusive realm of the
occupational therapist. Now we see signs that this is starting to change and
although it is still the occupational therapist who will do much of the formal,
standardized testing for sensory dysfunction, other disciplines are beginning
to recognize sensory integration dysfunction, make referrals for further evaluations, and incorporate a sensory approach.

We feel that knowledge is power and that by gaining a better understanding

of assessment terminology and the different types of assessment, you can
become a better advocate for your child and a more active participant in the
assessment process.
Psychological evaluation: Looks at whether an individualized program/special
education is needed, determines IQ (Intelligence Quotient), looks at behavior
and makes recommendations regarding behavior management. In older
children it looks at academic achievement.
Social history: Looks at the background information for illnesses, surgeries,
medications, birth history, developmental milestones, family history, and
previous school experience.



Audiology: Looks at the childs ability to hear, middle ear functiondetermines the absence/presence of middle ear fluid (which can affect speech) and
refers any possible ear infections to a physician.
Speech/language evaluation: Looks at

receptive languageunderstanding what is said

expressive languageuse of language to express ideas
pragmaticsrules of social language/communication
articulationhow clear a childs words are
fluencysmoothness of speech, rate of flow
voicequality and pitch of sounds (hoarse)
oral/motorstructure of the mouth.

Physical therapy evaluation: Looks at

muscle tonehow the muscles feel (are they tight or floppy?)
muscle strength, posture
flexibilityof joints and muscles
balance and coordination
motor skillsball skills, jumping, sitting, climbing, running,
walking, stationary movement, object manipulation
quality of movementwhether movement is easy or difficult,
variety of movement
breathing patterns
safety with movement.

Occupational therapy evaluation: Looks at

upper extremity developmentusing arms/hands in a
coordinated manner
fine motor skillsperformance of activities that require more
refined hand/finger movement and handeye coordination
visual-motor skillsthe ability to use motor skills to copy
designs that are presented in a picture
personal care skillshygiene, toileting, self-dressing abilities,
self-feeding (how the structures in and around the mouth are



visual perceptionhow a child perceives the visual world

around her through her non-motor responses (looking not
moving), looks at visual memory, visual discrimination, visual
figure-ground and visual closure
sensory functioninghow a child reacts to the information
that she is receiving through her senses and sensory systems
visionprovides an informal visual screening to identify
possible concerns that may require further evaluation by a

Criterion-referenced tests: These tests compare a students performance with a

previously established criterion rather than with other students from a normative sample. Normative means, for example, in comparison to other children
the same age.
Norm-referenced tests: These tests use normative data for scoring which include
performance based on age, gender or ethnic group.
Individual assessments: This type of assessment is usually a discipline-specific
evaluation performed by one member of a multidisciplinary team (speech
therapist, occupational therapist, physical therapist, psychologist, special education teacher, etc.) using both formal and informal assessment strategies.
Arena style evaluation: A multidisciplinary team composed of professionals
from various disciplines (occupational therapy, physical therapy, speech
therapy, child development, psychology, etc.) evaluates a child. Team
members usually develop an evaluation plan prior to the actual evaluation so
the same behavior can be observed from several perspectives simultaneously.
With this technique, usually one member of the team facilitates interaction
with the child while the other team members observe and document the
childs performance across a variety of assessment domains. The childs presenting needs will drive the composition of the assessment team.
Formal assessment: Standardized assessments are specific tests that measure
specific skills, abilities, and domains. Results are reported in a statistical
mannerpercentiles, age equivalents, grade equivalents, criterion-referenced, norm-referenced, etc.
Informal assessment: These are non-standardized assessments such as checklists,
rating scales, interviews, observation, or performance-based assessment. They



often draw upon professional judgment using observations presented in a

narrative, as anecdotal or supporting information.

Programs and services

Early intervention (Newborn to age three years)
Our focus as we look at the role of the evaluator, and the evaluation process,
will be on early intervention and preschool-age programs and services. That is
not to take away from the importance of school-age evaluations, programs
and services, but to emphasize the key role of early identification and early
intervention concerning sensory dysfunction. Honestly, we feel strongly that
this is where things need to start being put together and happening. Unfortunately, by the time a child enters mid to late elementary school the emphasis
shifts strongly to accommodation and behavior management.
In general, early intervention agencies/programs are designed to support
children to age three and their families in a variety of areas, including health
and wellness and child development, with one of the goals being for children
to acquire age-appropriate skills and be ready to learn. The goals of the early
intervention programs are driven by family concerns and family goals. In your
area, there may be opportunities for young children to receive a developmental screening through, for example, primary care providers, newborn intensive
care units, follow-up programs, etc. One role of early intervention programs is
to offer supplemental screenings or further evaluation opportunities for
children with a suspected developmental delay or disability. So, if you have a
child whom you suspect may have sensory integration dysfunction or significant sensory issues, we encourage you to discuss this with your pediatrician,
local early intervention program provider, or your school district. We also
encourage parents to be present and participate in their childs developmental
screening whenever possible. There is no doubt in our minds that parents have
proven, and continue to prove, that they are the single most accurate source of
information regarding their child and that they should always be welcomed as
partners in the provision of all early intervention services.

In many areas, children suspected of having a developmental delay may be

referred to an early intervention agency/program, and may be entitled to a
multidisciplinary evaluation.



A multidisciplinary team (sometimes referred to as multifactored) is generally made up of qualified individuals who have sufficient expertise and the
credentials to assess the childs present level of performance in each of five
developmental domains (cognitive learning development, language and
communication development, motor development (including vision and
hearing), language and social/emotional development, and adaptive skills

Preschool-age services (Children ages three to five years)


General education developmental screenings become significantly more

utilized during the preschool years. For example, a preschool program may
decide to provide developmental screenings to every child in their program.
Here the purpose may not just be to identify children with possible developmental delays, but to identify those children at risk, or to note progress over
time in a typically developing preschooler. Here, for example, a screening
tool may be administered by a general education preschool teacher at the
beginning and end of the school year to note progress for parent/teacher conferences. As more and more early intervention programs come under increasing pressure to provide outcome-based documentation of student progress to
help justify funding for the program, we also see an increased use of screening
tools. One benefit of the developmental screening is that it is usually easy to
administer (some training required), does not take long to administer, and can
provide valuable information as to how a child is developing in one or more
domains. The developmental screening can also help provide to families some
more concrete documentation (rather than just opinion) for a teacher or child
development specialist who feels a recommendation for further evaluation is

The purpose of this evaluation is to determine the childs present level of performance and if the child is eligible for any programs or services. The evaluation of a preschool child requires both information gathering from parents,
etc., and the administering of individual evaluations. These evaluations
should include a formal assessment, behavioral observations, and parent/
caregiver and/or teacher interview.



Ideally, individual evaluations should be written in a timely manner in

parent-friendly terminology, in the familys primary language. The evaluation
could include:

behavioral/clinical observations

test scores

relevant background information

significant temperament and personality traits (in the context of
the childs behavior)

description of needs/strengths
evaluation findings.


Since there is that wide range of variation in early child development and skill
acquisition among children, this needs to be taken into account when considering the potential eligibility of a preschool child for a special education
program and/or services. We feel that it is important for the parents, caregivers, and teachers of a child with a suspected developmental delay or disability to understand what the functional areas are and what skill deficits may
be considered when eligibility is considered. Ultimately, eligibility may be
determined relative to months of delay, percent of delay, and standard deviations, or a diagnosed medical condition. In a nutshell, whether you are a
parent of a child with sensory integration difficulties or the teacher of one (or,
as in our case, both), we feel it is imperative that you gain an understanding of
how your educational system works, what functional areas are of concern,
whether the assessment tool used was appropriate to determine the present
level of performance, and whether, ultimately, it gave an accurate picture of
the childs needs.
Significant sensory issues or sensory integration dysfunction are not necessarily going to be represented on many standardized assessment tools
outside of the occupational therapy/sensory domain. Therefore, parents and
professionals may need to search within the assessed areas for patterns,
behaviors, and deficits that may indicate sensory dysfunction and eligibility
for services.

Chapter 3

Concomitant Diagnoses

Sensory integration dysfunction is often referred to as a hidden disorder. As

moms, and now, as teachers, we get quite a laugh over that nicknamethe
hidden disorder. However, you may find that once you are familiar with the
behaviors and symptoms of sensory integration dysfunction, it is usually
about as hidden as an ostrich with its head in the sand or the grape juice
stain all over the front of the brand new, dazzling white t-shirt! These kids virtually scream sensory dysfunction in a variety of settings (school, home,
Grandmas, the grocery store, McDonalds, etc.) in their lives. In fact, when one
really stops to think about it, that is what makes it sensory dysfunctionit
appears to be the way their sensory systems work. Unfortunately, sensory dysfunction does not take a vacation, nor does it stay quiet and not manifest just
because it is Grandmas birthday and the whole extended family is at a fancy
It is our understanding that sensory integration dysfunction is rarely clinically diagnosed as a stand alone disorder, but is typically described and
diagnosed as concomitant (coexisting) with another diagnosis, or as an interwoven feature of another diagnosis. We feel it is important to gain an understanding of some of the more common diagnoses that sensory integration
dysfunction or sensory issues may be associated with, or embedded within.
The following is a listing of the more common diagnoses and/or conditions that may have sensory issues or full-blown sensory integration dysfunction associated with them.




Autism spectrum disorders

Down syndrome

ADD (attention deficit disorder); ADHD (attention deficit

hyperactivity disorder)

Cerebral palsy
Traumatic brain injury
Fragile X syndrome
Mental retardation
Premature birth
Substance abuse by mother during pregnancy
Fetal alcohol syndrome
Angelmans syndrome
Bipolar disorder
Oppositional defiant disorder
Emotionally disturbed
Conduct disorder
Obsessive-compulsive disorder (OCD)
Learning disabilities
Reactive attachment disorder

Again, this illustrates that sensory integration dysfunction is typically part of a

larger picture, and just because a child has received another diagnosis, does
not necessarily rule out sensory dysfunction. And, conversely, if for some
reason the child has received a stand alone diagnosis of sensory integration
dysfunction, it does not necessarily rule out a concomitant diagnosis.
At this point we would like to take brief look at Aspergers syndrome,
autism spectrum disorders, learning disabilities, ADHD, and bipolar disorder.
These diagnoses are becoming more prevalent in general education classrooms throughout the United States, and are those where we clearly see a
strong connection with sensory issues.



What is an autism spectrum disorder?

At this point we would like to address autism spectrum disorders (ASD),
which exist on a continuum. We believe that in virtually all diagnosed cases of
autism, there is a significant component of sensory dysfunction. The continuum ranges from PPD-NOS (pervasive developmental disorder, not otherwise specified) on the mildest end of the spectrum to severely autistic on the
other end of the spectrum. However, beyond recognizing ASD as a clinical
continuum, it is personal for both of us. We want people to understand and
relate to our children, and all of the children who are on the autism
spectrum. One of the primary reasons for including these DSM-IV definitions is to highlight the criteria needed for the clinical diagnosis of an autism
spectrum disorder to help in early identification and early intervention, and in
the development of appropriate services and individualized programming for
these children. If your child appears to be exhibiting some of the behaviors
consistent with these diagnoses, we recommend further evaluation by a
qualified professional.
According to the DSM-IV (American Psychiatric Association 2000), pervasive developmental disorders are categorized into five types:

autistic disorder

Aspergers disorder

pervasive developmental disorder, not otherwise specified


Retts disorder
childhood disintegrative disorder.

We are most concerned here with the first three of these, which are the autism
spectrum disorders. The DSM-IV criteria for these three diagnoses are here set
out in full (American Psychiatric Association 2000).

Autistic disorder
A. A total of six (or more) items from (1), (2), and (3), with at least two from (1),
and one each from (2) and (3):
(1) qualitative impairment in social interaction, as manifested by at least
two of the following:



(a) marked impairment in the use of multiple nonverbal

behaviors, such as eye-to-eye gaze, facial expression, body
postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to
developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests,
or achievements with other people (e.g., by a lack of
showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication, as manifested by at least
one of the following:
(a) delay in, or total lack of, the development of spoken
language (not accompanied by an attempt to compensate
through alternative modes of communication such as gesture
or mime)
(b) in individuals with adequate speech, marked impairment in
the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic
(d) lack of varied, spontaneous make-believe play or social
imitative play appropriate to developmental level
(3) restricted, repetitive, and stereotyped patterns of behavior, interests,
and activities as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped
and restricted patterns of interest that is abnormal either in
intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional
routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or
finger flapping or twisting or complex whole-body
(d) persistent precoccupation with parts of objects

B. Delays or abnormal functioning in at least one of the following areas, with

onset prior to age 3 years: (1) social interaction, (2) language as used in social
communication, or (3) symbolic or imaginative play.



C. The disturbance is not better accounted for by Retts disorder or childhood

disintegrative disorder.

Pervasive developmental disorder, not otherwise specified

This category should be used when there is a severe and pervasive impairment
in the development of reciprocal social interaction or verbal and nonverbal
communication skills, or when stereotyped behavior, interests, and activities
are present, but the criteria are not met for a specific pervasive developmental
disorder, schizophrenia, schizotypal personality disorder, or avoidant personality disorder. For example, this category includes atypical autismpresentations that do not meet the criteria for autistic disorder because of late age of
onset, atypical symptomatology, or subthreshold symptomatology, or all of

Aspergers disorder
A. Qualitative impairment in social interaction, as manifested by at least two
of the following:
(1) marked impairment in the use of multiple nonverbal behaviors such
as eye-to-eye gaze, facial expression, body postures, and gestures to
regulate social interaction
(2) failure to develop peer relationships appropriate to developmental
(3) a lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people (e.g. by a lack of showing, bringing,
or pointing to objects of interest to other people)
(4) lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and
activities, as manifested by at least one of the following:
(1) encompassing preoccupation with one or more stereotyped or
restricted patterns of interest that is abnormal either in intensity or
(2) apparently inflexible adherence to specific, nonfunctional routines or
(3) stereotyped and repetitive motor mannerisms (e.g. hand or finger
flapping or twisting, or complex whole-body movements)
(4) persistent preoccupation with parts of objects



C. The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning
D. There is no clinically significant general delay in language (e.g., single
words used by age 2 years, communicative phrases used by 3 years)
E. There is no clinically significant delay in cognitive development or in the
development of age-appropriate self-help skills, adaptive behavior (other than
social interaction), and curiosity about the environment in childhood
F. Criteria are not met for another specific Pervasive Developmental Disorder
or Schizophrenia
See Chapter 6, More About Aspergers Syndrome, for examples and explanations of these diagnostic criteria.

What are learning disabilities?

According to the Learning Disabilities Association of America (2005), the
term learning disabilities is really an umbrella term describing a number of
other, more specific, learning disabilities. Some of these specific disorders

dyslexiaa language and reading disability

visual perceptual/visual motor deficitreverses letters; cannot

copy accurately, loses place, struggles with cutting

nonverbal learning disorderstrouble with nonverbal cues, e.g.,

body language

language disorders (aphasia/dysphasia)trouble understanding

spoken language, poor reading comprehension.

dyscalculiaproblems with arithmetic and math concepts

dysgraphiaa writing disorder resulting in illegibility
dyspraxiaproblems with motor coordination
central auditory processing disorderdifficulty processing and
remembering language-related tasks

(Learning Disabilities Association of America 2005)



It has been our experience that children with learning disabilities often have
an underlying sensory processing component, and that, for these children, the
sensory piece should be addressed in conjunction with any prescribed strategies and treatments.

What is ADHD?
Attention deficit hyperactivity disorder (ADHD) is a condition that often
becomes apparent in preschoolers and early elementary school age. For these
children it is hard to pay attention and control their behavior. The principal
characteristics of ADHD are inattention, hyperactivity, and impulsivity.
Because many children exhibit these symptoms to some degree it is important
that the child receive a thorough examination by a well-qualified professional
before this diagnosis is made. According to the most recent edition of the
DSM-IV (American Psychiatric Association 2000) there are three patterns of
behavior that indicate ADHD. These are predominantly hyperactive-impulsive type (that does not show significant inattention), the predominantly inattentive type (that does not show significant hyperactive-impulsive
behavior)sometimes called ADD (although this is now an outdated term),
and the combined type (that displays both inattention and hyperactive-impulsive behavior).
Some signs of hyperactivity-impulsivity are:

feeling restless, often fidgeting with hands or feet, or squirming

while seated

running, climbing, or leaving seat where quiet behavior is


having difficulty taking turns or waiting in line

blurting out answers before hearing the whole question.

Some signs of inattention are:

often becomes easily distracted by irrelevant sights and sounds

has difficulty paying attention to details, makes careless mistakes

has difficulty following directions, loses personal items, forgets

things needed for certain specific tasks

often moves from one uncompleted task or activity to another.



It has been our experience that many children with a diagnosis of ADHD have
an underlying sensory component that may be impacting their attention
activity level and learning. We think it is important to assess and evaluate the
possibility of a sensory component in conjunction with the prescribed treatment for the ADHD.

What is bipolar disorder?

Bipolar disorder is often characterized by alternating periods of emotional
highs and emotional lows. This disorder can range from mild to severe. For
many people symptoms include, during a period of emotional highs:

feelings of euphoria, optimism

poor judgment

rapid speech, racing thoughts, agitation, increased physical


difficulty sleeping
tendency to be easily distracted
inability to concentrate
extreme irritability

During a period of emotional lows, symptoms include:

persistent feelings of sadness, anxiety, guilt, or hopelessness

disturbances in sleep and appetite
fatigue and loss of interest in daily activities
difficulty concentrating
recurring thoughts of suicide.

It has been our experience that for some children with a diagnosis of bipolar
disorder there is an underlying sensory component. During periods of an
emotional high an individual may experience a heightened sensory awareness or sensory feedback. In contrast, during a period of an emotional low
an individual may experience diminished sensory awareness or sensory



To medicate or not to medicatethis is the question

For many families, whether to medicate or not to medicate a child is a huge
issue/concern or dilemma. We feel it is a very individual, personal choice as to
whether or not to medicate your child. We have seen children where medication has been useful and effective, where medication has been neither useful
nor effective, and where medication has appeared to have some benefit. And
we have seen families who have felt strongly opposed to medication and have
opted not to pursue this as a treatment option. Our role (as parents or teachers)
is not to judge; weve walked in many of those shoes, and it is not easy. This is
why we feel so strongly that each parent, teacher, therapist, and physician
needs to be very informed. These are big, possibly life-altering decisions that
must be weighed carefully and monitored closely.

Chapter 4

Sensory Dysfunction at School

Everyone has a job to do

It is our belief that everyone working with a child plays an important role in
creating an effective and cooperative partnership on behalf of the child.

The teachers role

We encourage teachers to learn as much as possible about the childs delay or
disability, and consider possible links to sensory integration. In doing so,
teachers may want to take a new look at assessment, and begin to explore the
use of adaptations and modifications for their students. In support of home
and school partnerships, we feel it is crucial that teachers model an embracing
attitude toward families and students. We believe all children need to witness,
to feel, and to understand the benefits of tolerance and acceptance.

The parents role

We encourage the parents of a child with delays or a disability to become
advocates for your child. We would like to point out to parents that it has been
our experience that most teachers are doing the best they can (often with
limited training, experience, and resources). One reality may be that even the
most gifted teacher can have difficulty successfully integrating a child with
special needs into the classroom. Or it could be one of those instances where
the teacher and the student are simply not a good match.




What special education is, and is not

Because sensory integration is a common thread found in learning and development, children with sensory dysfunction may need the assistance of a
special education teacher to accommodate these differences in learning and
development. The paradigm for special education services in many countries
is shifting. The following is our frame of reference regarding the role of
special education services.
Special education is:

a service

ongoing training for all school personnel

providing the supports and services necessary for the student to


specific training when a classified student is included

a diverse classroom where the fundamental components are:
effective teaming with other teachers, specialists, support
personnel, administration, and parents
working knowledge of the childs educational needs
diverse instructional strategies
diverse management strategies

reflected in an attitude of tolerance and acceptance

each child achieving his or her potential as a student.

Special education is not:

a place

placing classified children into classrooms without the proper

services, supports and background information

requiring a teacher to provide a completely modified (and different)

curriculumthe child who colors in a worksheet while seated in
the back of the room with his or her aide, while the rest of the
class works on academics

designed to eradicate a disability.

placing several classified children with a teacher (because she or

he is willing to take them)this classroom then becomes a kind
of hybrid, modified special education classroom



Navigating the labyrinth of special education services can be a formidable

task. However, the personal and professional satisfaction that results from
understanding the system is well worth the effort. We believe that an understanding of and a respect for all students are the driving forces behind a caring
and committed teacher. Never underestimate your power to touch the life of a child!

The players on a childs team

As mothers of children with sensory integration dysfunction (and concomitant diagnoses), and as special education teachers, we bring with us the
parents perspective as well as the teachers perspective. And, not so surprisingly, we find there is much common ground. We see both parents and
teachers as addressing very similar issues: directing attention, social interaction, academics, living skills, social/emotional development, task completion,
and challenging behaviors.
Again it is important to realize that every school is different, and each
classroom in a school is unique. Your local area may have a slightly different
terminology for a specific positionin our schools, we have special education
teachers. In other schools, they may be referred to as consultant teachers, or by
any one of a number of titles. Thus, each child and teacher is really working
within a unique environment.
Here is a listing of possible school personnel and their typical roles.

Teachers are responsible for the academic curriculum, grades,

classroom management, scheduling, social and physical needs of
the students in the classroom.

Special education teachers are teachers who have a specific

certification to teach students with disabilities. The special
education teacher may provide services either directly to students
(classroom teachermany are special education certified, resource
room teacher, direct consultant teacher) and/or to classroom
teachers and support personnel (indirect consultant teacher,
resource room teacher).

Paraprofessionals may be a classroom para, who, under the

supervision of the classroom teacher, assists the teacher by helping
students and performing tasks in the room (e.g., gathering items
for a project, daily lunch count, handing out supplies and papers).



1:1 paraprofessionals are assigned to assist a specific student, and

accompany that student throughout the school day. A 1:1 para
will have very specific duties (as assigned by the teacher) that are
designed to support the student in all situations throughout the

Speech therapists teach language, communication, oral/motor, and

social skills to students who have deficits in these areas. Therapy
may be delivered inside the classroom, during an activitythis is
generally referred to as push-in therapyor the therapist may
take the student to his or her speech roomthis is generally
referred to as pull-out therapy (because the student is pulled
out of his or her classroom). The speech therapist is responsible
for addressing the pragmatic speech deficits in a student who has

Occupational therapists are responsible for helping students who

have recognized deficits in the areas of fine motor function,
eyehand coordination, and sensory dysfunction. OTs help
students who have difficulty using their hands for school-related
activities (printing, writing, using scissors, manipulating small
objects) or life skills activities (buttoning, zipping, tying shoes,
using eating utensils). Some OTs also help students who have
been diagnosed with sensory dysfunction. Therapy may be
delivered on a push-in or pull-out basis.

Physical therapists are responsible for providing therapy for students

who have recognized deficits in gross motor function. PTs help
students who have mobility, muscle strength, and coordination
issues. PTs may also treat students who have sensory dysfunction.
Therapy may be delivered on a push-in or pull-out basis.

Adapted physical education instructors are responsible for designing

and implementing a physical education program for students who,
due to their disabilities, are not able to participate in the schools
general education physical education program.

School social workers are usually certified (CSWcertified social

worker) and/or have a Masters degree in social work
(MSWMasters in Social Work). Social workers help students
work through personal, family, and social problems.



School psychologists usually have an advanced degree in some form

of psychology, typically child psychology.

School nurse.

Analyzing possible sensory dysfunction and offering solutions

Before we analyze specific situations, lets take a look at some basic level
problems and possible solutions. This will be helpful when it comes time to
tease apart complex situations.
We will consider some of the more common areas of sensory difficulties,
followed by a list of functional, practical suggestions.

Auditory dysfunction

Verbal warnings help a great dealClass, the cafeteria is going to

be noisy

Student may wear noise-muffling headphones (now there are some

very unobtrusive headphonesmuch less geeky).

Allow student to listen, with headphones, to music that they enjoy.

Consider allowing the use of a tape recorder for the student to

listen to a lecture or instructions again at a later time (not in place
of listening when information is being delivered).

Allow student to cover ears.

Offer a less noisy alternative, if possible (either a less noisy spot in
the same place, e.g. the corner of the cafeteria, or sometimes a
different place is available; sometimes a student can go somewhere
a few minutes early, to avoid being in the middle of the din).

Tactile dysfunction

Help student recognize and verbalize issues and sensitivities as much

as is possible (the more the student is a part of the process, the
better the outcome will be).

If student is tactilely defensive (does NOT like to be touched or to




allow the child to wear gloves, so his skin does not have direct
contact with the aversive texture
introduce aversive textures slowly, allowing students to build up
tolerance at their own pace (if everyone else is having pretzels
for snack, but Breon finds crunchy to be aversive, ask him to
try one bite (or maybe just Hold the pretzel for a moment,
then you can have your banana)
recognize that a student may need a cotton towel or piece of
cloth on his chair or place on the rug because the texture of
the chair or rug is too aversive/distracting.

Allow the student to be either the line leader or the line caboose
(but never in the middle of the linebelieve us, the complaints of
being touched will begin before the class has exited the room!).

Gain tolerance to textures by small, frequent exposures to a variety of

textures (hands/feet in dry macaroni, beans, birdseed, packing
peanuts, water, playdough, frosting, shaving cream, cotton,
Velcro, synthetics, tacky glue, finger paints).

If the students crave tactile input and have their hands all over
everything and everyone
tell social stories about appropriate times and ways of touching
use a hula hoop for establishing personal space boundaries
(place hula hoop on ground, have student stand in the middle
to help visualize personal space boundaries for self and
allow a squeeze toy or fidget toy (tennis balls work great!) to
squeeze throughout the day
allow younger students to have a small square of carpeting or
towel to define their space when seated or standing
have a hand pouch (two handkerchiefs sewn together) ready
for student to stick hands in.



Gustatory (taste) dysfunction

For aversions, introduce slowly, perhaps with a sniff at first, then

slowly progressing to a quick lick (then spit out if necessary), then
to a bite that is swallowed.

For sensory cravings, sometimes the amount, place, and times

need to be well defined and explained ahead of time (Rita, you
may have one cookie after breakfast, then one after you get home
from schoolat 3:15these are the only two times you will get
a cookie).

Olfactory (smell) dysfunction

Attempt to have adults not use perfume or colognes or body lotions.

If possible, match the scents of shampoo and deodorant, so your

body is not emitting a potpourri of scents.

Try to use art supplies and classroom supplies that are unscented or as
lightly scented as possible (unscented markers, playdough, glue,
Kleenex, air fresheners).

If a student cannot tolerate a smell that is wafting through the

building (from the cafeteria, from general cleaning or painting,
from the art room, etc.), attempt to remove the student as much as
possible from the smell:

If possible, use shampoos, conditioners, and deodorants that are

not strongly scented.

close classroom door

position child near open window
use a small fan near the child to blow the scent away (this
worked the best in our classrooms and all of the kids loved it)
place a scent the child likes near the child to offset the
unwelcome scent as much as possible.

Visual dysfunction

Assess the learning environment for placement and quantity of visual

stimulus. Every classroom needs to be a celebration of the
achievements and efforts of the studentsbut is the classroom too



busy visually? Is every inch of space taken up, creating a visual

montage? Or are work, art, and projects displayed in a thoughtful
manner, provoking a creative, organized atmosphere?

Use icons, words, or words and icons together (mounted on index

cards) to help refocus, to promote staying on task and to minimize
behavioral issues.

Use sign language to back up words and/or icons. Very useful

during transitions times, classroom group time, and during large
(noisy) crowd timescafeteria, assembly, recess, physical

Use exaggerated facial expressions (typically a child with ASD and

often a child with sensory issues will not get the subtle nuances
of facial expressions or someone who is talking with her eyes).
Of course, the student needs to be practiced in what these facial
expressions mean ahead of timeOh, I get it, Mrs. Emmons, that
is your I dont understand look!

Define the layout of the room by physical boundaries.

Consider providing the student with:

Use real objects to define abstract idease.g., hula hoop for space,
clock that shows by color how much time is left for an activity (or
waiting time), a circle that is red on one side and green on the
other side (either attached to a popsicle stick or hung around the
neck with yarn) that can be wordlessly flipped by the teacher or
paraprofessional to indicate when a child needs to be quiet (and
not interrupt), or can ask questions or volunteer information. Use
realistic manipulatives (something that looks and feels like the
actual object, e.g. small plastic coins) whenever possible.
a study guide for a topic or lecture
an outline where the student is responsible for filling in the
details (this works well, helping to keep the student on track
and not just attempting to write down every word).

Children who have autism spectrum disorders are, overwhelmingly, visual

learners. However, visual schedules will prove to be a lifeline for many

Individual schedulesicons only, words only, icons with words,

color-coded; subtly included in students notebook, posted on



board, taped to desk (inside plastic protector), carried by student,

teacher or paraprofessional.

Classroom schedulesicons only, words only, icons with words,

color-coded, laminated, posted on board, above door, etc.

First circle time

Then free time

Then snack time

Figure 4.1 Examples of preschool-age icons for more effective transitions. Teachers may also
choose to use generic photos, personalized photos or hand-drawn sketches as visual supports.

I need a break

I dont understand

Figure 4.2 Examples of school-age icons for more effective communication


Science centre (rocks and minerals)

Reading group (Chapter 2)
Restroom break
Physical education (soccer)
Math group (homework p.217)
Work on social studies project (individual)
Lunch in cafeteria (pizza or cheese sandwich)
Playground (outside if no rain; room 15 if rain)
Language arts (have colored pencils out)
Global studies (whole class)
Restroom break
Speech with Mrs. Jamison
Ready for home (bookbag, homework folder)

Figure 4.3 Andrews schedulean example of a visual schedule using words only



Proprioceptive dysfunction

Allowing the student to wear a weighted vest may help (easy to

make), or a knapsack with some weight.

Use a non-slip mat to prevent student from sliding out of chair so


Use a non-slip mat to hold pieces of paper or worksheets in place.

Let student listen while sitting on a large physio-ball or T-stool.

A mummy-style sleeping bag to wrap (swaddle) into may improve

listening ability in many children with sensory dysfunction who
crave deep pressure.

The peanut butter and jellyhave child lie on mat, then cover
with heavy blanket(s) and gently squish the childwith even,
deep pressureOT or PT should instruct on usage.

Allow student to stand at desk at various times.

Allow student to walk up and down stairs.
Supply a chubby pencil grip for holding on to pencil.
Allow student to wear an adjustable belt or waistband around waist.
Give student a tennis ball to squeeze.
Joint compressions may be helpful (a technique that needs to be
learned from a certified OT or PT and closely supervised).

Let student give self a bear hug.

Have student carry something with weight or hold a couple of
books (if seated).

Vestibular dysfunction

Schedule periods (varying from quite brief to extended) of

activities involving motion: swinging, jumping, slide, physio-ball,
walking, climbing stairs, see-saw, mini-trampoline, dancing.
Periods of these types of activities before a period of quiet
listening or working may help to organize the sensory systems so
the student will be more able to be calm and focused. They may
be part of a sensory diet program for a student to help organize
and focus the sensory systems.



OT or PT may place the students on suspended equipment, such

as bolster swing, netting swing, four loop (two kids with legs
through loops) swing, platform swing, etc.

PT/OT/teacher may also use equipment such as roller skates,

balance beam, scooter board, balance board, etc.

The teacher as detective

It is time to put together the pieces of the puzzle. In order to solve the puzzle,
we must put on our detective hats, learn to analyze problematic situations,
and develop useful strategies to resolve these situations.
Anytime a difficult situation arises (behavioral, social, academic), the situation must be broken into its component parts and analyzed individually. The
first aspect to analyze is the behavior; what does it look like (describe)? Next,
what happened just before the situation (pre-behavior situation)? Then, because
this is sensory integration dysfunction we are discussing, we need to know
what happened several hours (or days) before (at home, on the bus, at the
sitters last night) that might be related (never forgets factor). Finally, we get the
point of view (POV) of the child who has sensory dysfunction or Aspergers.
The POV of this child may be very different, distorted or, most likely, narrow,
compared to the POV of his or her peers on the same situation.
After getting all the components together, the teacher must analyze all of
the information to discover the major causal factors. Then it is up to the
teacher and the school team to develop a workable strategy, and to implement
that strategy.
Lets get started! We will look at three case studiesone from a preschool
class (Brittney), one from an elementary school (Tyrell), and one from the
middle and high school years (Cody).

Preschool class
Brittney is a four-year-old girl, who was a premature baby with a history of
frequent upper-respiratory infections. She was described by her teacher as
generally pleasant and cooperative in her preschool class. Her teacher and
parents are becoming concerned because things are not coming together for
her. Brittney arrives at school in slow gear, requiring a lot of attention to get
settled in. Her teacher says she is always several steps behind the rest of the



class. It is now May, and her teacher and parents are looking closely at her
level of readiness skills for kindergarten.
The absolute first thing we do is ask: What does the behavior look like?
In other words, describe exactly what is meant by slow gear, not coming
together. If we were strangers walking into the classroom for the first time,
what would we see Brittney doing?

What does slow gear look like?

Walks in slowly dragging her backpack behind her.

Affect is flat, does not spontaneously greet others.
Her nose is running and her mouth is slightly open.

What does several steps behind look like?

Wanders around instead of going directly to her cubby when


Requires assistance getting backpack hung on the cubby coat

hook and getting her jacket off.

Still needs repeated prompts to choose a place to play while other

kids arrive.

Transitions slowlyother kids are already sitting in the group

while she is still finishing clearing her area from the previous

What does not coming together look like?

Has a hard time grasping and retaining concepts.

Limited vocabulary, limited use of pronouns, difficult to

understand much of the time.

Still has difficulty playing simple group games.

Does not actively participate in cooperative or group play.

Is not developing a mature pencil grasp, cannot trace her name
without assistance.

Often appears detached and not attending much of the time.




Arrival: Ms. Williams greets the children and takes attendance

while the children trickle into the room. Then Ms. Williams
reminds the children to put their things in their cubby and choose
a place to play.

Depending on the day, the children will transition to group time

about 2025 minutes after arrival.

At group time the children participate in either a literacy, science,

math, or music and movement activity related to the theme of the


Unidentified at this time due to limitations of her language skills.


Arrival: Brittney indicated that she likes coming to school, likes

the toys and likes her friends. My bag is big. I dont know where
my cubby is. Its ok.

Transition time: Where does this go?

Group time: Its fun.


Arrival: Backpack is heavyproprioception, muscle tone,

strength, endurance
Finding cubbySensory processing of the visual, auditory,
motor planning, vestibular? Due to frequent upper-respiratory
Hanging backpackProprioception, motor planning, body
Finding a place to playDifficulty prioritizing sensory
stimuliwhat do I attend to first?Is the teacher talking to
me? Sensory overloadtoo many choices?
GreetingsLanguage delay, difficulty organizing and
formulating a response


Transition timeDifficulty prioritizing sensory stimuli, language

processing issues

Group timeProprioceptive, tactile, auditory, visual, vestibular



After the parent/teacher conference, the parents requested evaluations by the

speech therapist, child development specialist, and occupational therapist.
Here were the suggested strategies.

Visual cues to redirect attention and guide (visual schedule,
photo in cubby)
Modeling appropriate greetings
Provide larger hook for cubby
Alerting activity
Teacher to limit choices for arrival activitychoice of two.
Brittney chooses where she wants to play from two pictures.
Teacher prompts her to use I statementI want to play
with the

Transition time:

Give verbal warnings prior to transition

Use of visual timer
Break down task
Use of transitional song or music (the clean-up song)
Delineate physical spacewhere do you sit?

Group time:

Wake up your body activity

Visual cues for redirecting
Verbal prompts for redirecting
Preferential seating
Sitting on bumpy side of Move n Sit cushion
Visual schedule
Encourage participation/movement



After implementing some of the strategies that had been suggested by the
team, Brittneys parents and teacher are encouraged by some recent positive
changes. Brittney is now more independent (removing coat, hanging book
bag in cubby), is experiencing smoother transitions between activities, and
has increased her level of participation in group activities.

Elementary school
Tyrell is a bright child who is driving his 1st grade teacher, Mr. Grady, insane!
It seems to be the same issues every day. Tyrell interrupts during morning
circle and is constantly talking about carnivorous plants. When the class
breaks into groups and travels from center to center, Tyrell is usually off task
or complaining that a classmate is bugging him. Mr. Grady is spending a
large portion of his time redirecting Tyrell.
The absolute first thing we do is ask: What does the behavior look like?
In other words, describe exactly what is meant by off task; how is Tyrell interrupting? If we were strangers walking into the classroom for the first time,
what would we see Tyrell doing?

Interrupting looks like:

sitting on the rug and squirming continuously

distracting the other students by talking to himself out loud.

talking without raising his hand when he wants to answer or add

something to what Mr. Grady is saying

Center time behavior looks like:

Tyrell looks like he is lost in a fog:

looking all around the room
asking many obliquely related questions, then switching
rapidly to talking about carnivorous plants before getting an
answer to the question he just asked
looking at the teacher, the classroom aide, and the clock

Tyrell appears to be quite clumsy, getting too close to his

classmates or to furniture:
he often jostles classmates (unintentionallythen blames them)



he bumps into desks and chairs and blames the furniture, or

the person next to him.

Circle: Mr. Grady conducts daily classroom businessattendance,

lunch count, etc., while the class sits at their desks. Then Mr.
Grady tells the class to come over to the rug for morning circle.

Centers: Depending on the day (the school follows a six-day cycle),

Mr. Grady will start centers between 9:30 and 10:15.


Mr. Grady spoke to Tyrell in an informal way, during a quiet time. He discovered that, for the specific day of the observation, Tyrells mother cooked
oatmeal for breakfast because his little sister wanted it. Tyrell hates oatmeal, it
makes him want to throw up. Tyrell ate his usual breakfast of a blueberry
muffin and a spoonful of peanut butter. Also, he outgrew his favorite pajamas
and his mother is getting him new ones todaywhat if they dont have dinosaurs on them?

Circle: The rug is real itchy. The other kids are always bumping
into me or kicking me for no reason. Carnivorous plants are very
interesting. You ask questions, dont you expect me to answer?

Centers: [Heavy sigh] Centers are too confusing! I never know

where Im supposed to go next. Remember when I was timed out
because I didnt know where to go and you said I did? You said
that each center would be 10 minutes, but sometimes a center is
longer than 20 minutes, or shorter, like only 8 minutes. I never
know if Ill finish before you tell us to rotate. Besides, people are
always pushing their chairs out right in front of me or standing
where I want to stand.


The rug is itchy and kids are always bumping into
Carnivorous plants are interestingPragmatics.



Centers are confusingSensory-executive functioning.
Centers are supposed to be 10 minutesInflexibility/pragmatics.
People are pushing chairsPhysical proximity/sensory.


Mr. Grady enlisted the help of the school speech therapist and special education teacher to help him devise strategies to help Tyrell. Heres what the three
of them came up with.

Cotton bath towel that Tyrell may sit on (washable and
portable, too).
Decided to let the towel serve as a physical space prompt.
Used a laminated circle (red on one side, green on the other)
as a stopgo signgo for raising your hand, and stop for
no interrupting by raising hands or talking out loud.
Mr. Grady even had an index card that said on topic ready
to point to if Tyrell (or anyone else) responded with a
completely off-topic remark or story.

Mr. Grady purchased a timer for the classroom, that showed
how much time was left in red.
Posted a rotation schedule that all of the groups could
easily follow.
Created a stay on task card for Tyrell, which Mr. Grady or
the classroom aide could easily and inconspicuously flash to
Tyrell (or any other student).
Mr. Grady or Mrs. Guiles (the classroom aide) always gave a
verbal one minute warning before it was time to rotate to
the next center.
Mr. Grady incorporated carnivorous plants when appropriate.
For the bumping issue: the towel or a hula hoop; and social
stories about accidental bumping and awareness of personal



Mr. Grady and his team were flabbergasted by the results of the strategies they
had implemented. Many other children in the class benefited from the
changes as well, not just Tyrell. The class was actually running quite smoothly
and Mr. Grady was no longer exhausted by 9:15am!

Middle and high school

Cody is a 13-year-old boy who is often sullen and frustrated because he does
not seem to fit in at school. His teachers are frustrated because Cody is completely disorganized and usually seems to be on the edge of having an angry
outburst or a tearful meltdown, even when someone is trying to help him!
Cody is smart, but does not work to his academic potential. Codys teachers
schedule a meeting to discuss Codys problems.
During this meeting, Codys teachers realize that he is having difficulty in
each of his classes with behaviors and not getting homework done or handed
in on time.

Behaviors look like:

sullen and unhappy

off taskstaring out the window or just staring into space

becomes angryslamming books shut, loudly talking to himself

usually to class late and without the required homework, books,
or supplies

cannot seem to follow simple directions given in class

anxietyalmost hyperventilating while repeating, I, I, I just
dont understandIll never be able to do thiswhy me?

Homework is:

usually a day late and/or partially completed

very sloppymany erasures or scribbled-out portions
very large and difficult-to-read handwriting
often not as instructed.




Behaviors: At the beginning of the school year, each teacher

established rules about the behaviors expected in his or her

Homework: At the beginning of the school year, each teacher made

clear her or his expectations and rules about homework


Codys teaching team selected one member, Mrs. Lopez, Codys science
teacher, to talk with him about his day on one specific day. Cody spoke
quietly and was near tears. Mrs. Lopez was surprised at how Cody worried
about getting on the right bus after school, because a classmate, Lon, made
fun of Cody in the 5th grade for absentmindedly getting on the wrong bus.
Cody is also worried that some of the wild boys will lock him in his locker
and he will die of asphyxiation. Also, too many bad grades will prevent him
from getting a scholarship to a good four-year college.

Behaviors: What am I supposed to do? All of my teachers are out to

get me. I never can do anything right. Slamming a book shut is a
lot better than punching someone (which is what I wish I could
do). I can never hear the teacher, there is always someone else
talking or ripping paper from a notebook or tapping a pen. How
can I concentrate with all of those distractions? When I think
about karate, my favorite thing in the whole world, all of the
noise goes away and I can imagine myself doing a form or a
flying side kick! Then, all of a sudden it is time to go, and the
teacher is talking about homework in a really fast voice and he
knows Ill never get it finished because it is always too much
then what about getting into a good college?

Homework: I never know how long the homework is going to take

to do. Sometimes I dont get the assignment written down or I
lose it in my locker or somewhere. I get home and my mom wants
me to do the homework, but I get confused about how to do it.
Sometimes I get really mad because I lug all these huge books
home and somehow I dont have the right ones! Then everyone



nags me because my writing is illegible. My hand hurts from

writing and it still looks terrible. Even when I get my homework
done and handed in on time, I still make mistakes on it and get it
back with corrections.


DisorganizedExecutive functioning.
Difficulty understanding/interpreting directionsPragmatics.
Difficulty understanding/interpreting directionSensory.
Anxiety issues.


OrganizationExecutive functioning.
Difficulty understanding/interpreting directionsPragmatics.
Difficulty writing out assignmentsSensory/pragmatics.
Anxiety issues.
Difficulty coping with feedbackPragmatics.


Codys team of teachers got together with a special education teacher and an
occupational therapist. After brainstorming, here are the strategies the team
came up with:

Color-code all books and folders according to subject area
(science book has red cover, science notebook is red, science
folder is red).
Make sure Cody writes down all assignments (at first, have
teacher, paraprofessional write down assignmentsgradually
make Cody responsible for writing in agenda).
Reduce the amount of homework, for example by just doing
odd-numbered questions.
Discuss possibility of using computer to type some
homework, to alleviate writing problem.



Have paraprofessional, teacher, or older student(s) anchor at

the end of the day to help Cody go over agenda and gather
correct homework supplies.
At home, have a permanent study area set up and readya
place with few distractions, yet easily accessible to parents for
Graph paper to line up math problems.
Timerwork for 15 minutes, then three-minute break.

At school:
An adult anchor that Cody meets with at the beginning of
every day to make sure that things are running smoothly,
homework was completed, quickly review his schedule for
the day, etc.
Have adult assist with initial organization of locker and
color-coded subject areas.
Color-coded checklist of needed materials (science, social
studies, and gym clothes for the morning).
Allow Cody to stay at locker a couple of minutes longer to
use checklist for supplies.
Preferential seating in classes.
Prearranged signal that allows Cody one or two minutes of
quiet, unobtrusive break time when he becomes
overwhelmed and feels like lashing out or crying.
Encourage Cody to practice breathing techniques when
experiencing stress or anxiety.
At the end of the day, anchor person helps Cody create a
visual schedule for the next day, including any known
substitutes, assemblies or other changes in the schedule.

By the middle and high school years, a student who has Aspergers or sensory
dysfunction is likely to be plagued by depression and riddled with anxiety. It
becomes critical for such a student to have an adult anchor, with whom they
touch base at the beginning and end of each school day.
Codys teachers were reluctant at first to put time into scheduling the
things that Cody should be doing independently by now, such as writing in
his agenda and making out his own daily schedule, plus taking the time to



meet with him at the beginning and end of school. However, the teachers
agreed to a trial run, and appointed a paraprofessional as the anchor person.
By the end of the trial period, Cody was much less sullen and almost
always had his homework completed, and in on time. His emotional meltdowns were much less frequent, and his parents reported that homework time
was no longer a daily battle of wills.

Behavior as a means of communication

Behavior, behavior, behavior. More importantly, what is the child telling us? It
is our experience that behavior is perhaps the most powerful means of communication a child possesses. For children with sensory issues (to full-blown
sensory integration dysfunction) behavior is often misinterpreted or misunderstood, and as a result, the situation seldom improves, frequently resulting
in a vicious cycle or a power struggle. It is our assertion that if you (as parents,
teachers, therapists, etc.) become more aware of the intent of the behavior, it
might become easier to develop more effective/successful behavioral

Physical proximity issues
High/low activity level
Emotional lability
Low frustration level
Shut down
Runners and hiders
Aggression (physical, verbal)

Now, because it is our assertion that many times it is the sensory issues/needs
that drive the behavior, it makes sense to begin to tease apart challenging
behaviors using a sensory-based perspective. Again, the senses and the



sensory systems do not work in isolation. So, generally speaking, you will
need to consider more than one system or sense when analyzing behavior.

PerseverationCraving/aversion of a specific sensory input

(tactile, visual, vestibular, auditory, proprioceptive, gustatory,

Physical proximity issuesA consistent need to be too close (in

another persons space) or a consistent need to maintain an
inappropriately far distance (tactile, proprioceptive)

Hyper activity levelChildren who get revved up quickly and

have a lot of energy, but the energy tends to be diffused (visual,
auditory, vestibular, tactile, difficulty prioritizing stimuli)

Hypo activity levelTakes a long time to get revved up,

appears to lack energy, what energy they do have tends to be
diffused (visual, auditory, vestibular, tactile, difficulty registering

Emotional labilityA child who vacillates emotionallylaughing

one minute, sobbing the next (sensory processing, sensory
overloadunable to regulate)

DistractibilityShifting focus frequently and abruptly, attention

is fleeting (difficulty prioritizing stimuli in all senses and sensory

Low frustration levelEasily frustrated (motor planning, delayed

skill development for specific activity, sensory overload)

Shut downRefusal or inability to respond (sensory overload)

Non-complianceResisting or refusing to respond to a task or

activity (an aversion to a specific sensory experience, or inability
(actual or perceived) to perform task)

Runners and hidersChildren who bolt, leave, exit an area with

out permission; children who hidewhen it is not a game of
hide-and go-seek! (seeking a certain type of sensory experience,
avoiding a certain type of sensory experience)



AggressionPhysical violence or the threat of physical violence

(sensory overload, perceived threat, actual or perceived inability to
perform task)

Home/school partnerships
It is our belief as well as our experience that effective communication is the
absolute cornerstone of effective home/school partnerships. This is the only
way that you can have a truly win-win-win (parents, school, and, most importantly, the child) situation. We are keenly aware, both as teachers and as
parents, that truly effective communication requires at least willing participants. In other words, if the parents are not fully participating or the school is
not fully participating then everyone is not at the table.
In the Perfect World

the home and the school intentionally, quickly, build a positive


the family is well-informed and respectful of the childs school life

communication between home and school is as frequent as is

needed and is thoughtfully sent and thoughtfully received

home and school both have enough time and resources to share
victories and positive experiences

parentteacher conferences (phone or in person) are occurring and

they are constructive and collaborative

everyone is on the same page and mutually supportive of goals.

school personnel are well-informed and respectful of the childs

home life

Some questionspossible solutions?

Is everyone committed to building positive rapport?Are there

participants who are talking down to others, using jargon, or
whose communication (verbal or nonverbal) might be construed
as negative or demeaning?

Does the family have a true understanding how their childs program
functions?Has the family been given information, in their



primary language, explaining their childs program(s) in terms

they can understand?

Do the school personnel have a basic idea of how things function at

home?Has the school been given appropriate, pertinent
information to aid the school in understanding the childs

Are there limitations at home or at school? If so, are all parties

informed?Is it a family situation that could affect the childs
education program? Is it a school situation that could affect the
childs education program?

Are you acknowledging the other parties efforts?As the family are
you taking the opportunity to note and to appreciate the effort
being made by the school on behalf of your child? As the school
personnel, are you taking the opportunity to note and to
appreciate the effort being made by the family on behalf of the

Creating a plan
Effective communication can occur in several different ways. We have found
that creating a plan using focused questions will usually be a great help to the
child with sensory dysfunction. Of course, the obvious first choice is that the
home and school collaborate by answering these questions and devising a
strategy separately or by scheduling a time to develop the plan together. For a
variety of reasons, this may not always be possible. A form that can be used at
home or in school might include the following:

childs name
date of birth
sensory profile
resources available (people, equipment, time, and money)
areas of strength
areas of difficulty (list in order of priority)



what is already working (strategies, incentives, etc.)

who/what do you need to access? (additional resources needed)

what specifically do you want to see changed or improved?

(behavior, skill development, social interactions, self-care skills,

strategy to address target behavior from a sensory perspective

a record of how strategy is working
whether to continue/discontinue strategy.

Developing a student/child portfolio

Another, more comprehensive way to communicate and share information
home to school, school to home, or during transitional situations, whatever
those could be, is to put together a portfolio. An outline of the information
contained in such a portfolio is presented on the following pages (pp.1028).
This portfolio is most commonly used in preschool and early elementary
settings. It is time-consuming and you do need to know the child well.

Adapting to the child

We view the senses, and sensory systems, with regard to learning, as individual building blocks of differing sizes and shapes that fit together to build a
strong foundation. It is our view that this could look like a country-style stone
wall where you are grabbing stones from the field and fitting them together as
best you can to build a solid wall. For some individuals, this developmental
wall comes together effortlessly and naturally over the course of their early
years. For others, this wall takes a lot a work and ranges from unsteady to
already shifting, beginning to show gaps, and crumbling. The blocks are the
senses, the sensory systems, skill development, learning, and behavior. For
some individuals the senses and sensory systems work well cooperatively to
help, seemingly effortlessly, develop and support age-appropriate skill development, learning, and behavior. For other individuals, the senses and sensory
systems do not work well cooperatively, which may result in developmental
delays, learning difficulties, and behavioral problems.

Basic Child Information
Childs name
Current address

Phone #
Parents, significant people



Allergiesfood, medication, etc.

Food preferences/aversions

Diagnosis, if any

Pertinent previous medical and/or sensory history

Prior and current related services, if any

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005

Communication Abilities
Alternative/augmentative forms of communication (examples:
sign language,visuals as language supports,picture exchange communication system, etc.)

Strategies for communication that work for this child (examples:

pause before repeating a question, using a quiet voice to gain

Intelligibilitywhat helps support childs ability to be understood? (examples: cues to slow down, cues such as bite your lip
for the letter F)

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005

Motor Needs/Adaptations
Adaptive equipment child may need (examples: special seating,
slant board, loop scissors, special pencil grasp)

Helpful hints (examples: reminding child to hold rail on stairs,

placement in line, type of movement that child seeks, movement
child avoidsclimbing, crawling, swinging, crashing, jumping,

Does the child have a sensory diet? If so,what was included in it?
(examples: brushing program, spinning program, weighted vest,
weighted lap belt, suspension equipment, taking regular breaks
from classroom)

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005

Classroom Management
ReinforcersWhat is reinforcing to this child? (examples:
encouragement and praise, time doing a favorite activity)

RelaxersWhat relaxes this child? (examples:looking quietly at a

book, squeezing playdough, deep pressure activities such as
jumping, pushing against the wall, getting a bear hug, listening
to music with headphones on)

Transition timesHow is this child during transition times? If

transition is difficult, what was helpful to use? (examples: fiveminute, three-minute, one-minute auditory warning, use of a
visual timer, visual schedule to see what is coming next, a picture
of what is coming next to hold)

Behavior managementDid this child have a specific behavior

management plan to address challenging behaviors? If so, what
were some of the challenging behaviors? How were these handled
in the classroom? (examples: planned ignoring, reward system,
clear and consistent consequences)

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005

Learning Style/Curricular Adaptations
Attention span
Compliance level
Learning style
Curricular adaptations (examples: tasks broken down, directions
repeated, directions supplemented with visual support, preferential seating)

Play skills (examples: associative, cooperative, level of adult

support needed)

Favorite learning centers

Favorite subject areas

Group activitiesHow does child respond to individual vs. small

group vs. large group instruction?

Extracurricular activities

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005

Work Samples
Art work (self-portrait, free art, paintings etc.)

Writing sample

Cutting sample

Photos of child in home or school setting

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005

Abbreviated Secondary School Form
Students name
Students age
Students date of birth
Prior placement

Prior services/accommodations/modifications

What worksacademic

What worksbehavioral

What does not workacademic

What does not workbehavioral

Areas of high interest/hobbies/sports/clubs

Adapted from Handicapped Childrens Association, Inc. portfolio guidelines

Copyright Polly Godwin Emmons and Liz McKendy Anderson 2005



Getting ready to learn

It is our experience as teachers that one cannot work on the assumption that
all children come to your classroom or activity ready to learn. This can be for
a variety of reasons (illness, fatigue, family issues, etc.), but we are going to
look at the possible sensory components to attain that optimal quiet alert
state in order to be ready to learn. The challenge is that some children will
arrive that are over-stimulated (you know, the students who are buzzing
around the room and may need to be peeled off the ceiling), while other
students will arrive under-stimulated and under-aroused (yawning, head
resting on hand, sleeping with eyes open). It is our stance that whether you
teach preschoolers or secondary students, it may be well worth your time to
develop a (literally) one-minute routine that will help to improve focus and
better organize your students sensory systems to achieve that quiet alert
state. This routine can be strategically utilized prior to starting an
activity/lesson, during an activity/lesson, or after an activity/lesson as a transition to the next thing. You know your students best! You know when they
need a break or need to reorganize, regroup or refocus. We are suggesting that
you review your daily routines from a more sensory-based perspectiveaccessing the sensory systems to facilitate that quiet alert state. After
incorporating a more sensory-based approach, we are confident that it will
prove beneficial for your entire classroomyour students and yourself !
This routine can and should look different, depending on many factors,
including, for example, age level, the type of activity that you are going to be
engaging in, time of day, and time of year.
Lets say you are a preschool teacher and have a great science activity planned
for circle time. You are just coming out of snack and beginning to gather the
kids on the rug. It is now October, so you can easily anticipate that four kids
will be over-stimulated by the transition from snack clean up, three will not be
sure that circle comes after snack every day (wandering), three will be
tired/lethargic and generally under-aroused and not have started to perk up
yet. Here is a routine (after your regular transition song/movement/music
activity) that might work for your classroom.

As kids gather, let them know that its time to wake up our
bodies and get ready to learn.

Wake up your eyesget them ready to look (rubbing temples).



Wake up your earsget them ready to listen (massage ears).

Wake up your brainget ready to think (scalp massage).

Reach up high and stretchfeel your shoulders and stretch your

arms (posture awareness).

Stretch out your legspoint and flex feet and toes (body

Pat your armsgive them a rub, then a pat (body awareness).

Wake up your noseget ready to smell (touch nose, crinkle


Wake up your cheeks, chin, eyebrows, elbows, ankles, etc. (by

rubbing or rolling or bending).

Take three deep breaths, roll your neck.

Now we are ready to learn.

You will know day to day, how and when it needs to be tweaked a little bit and
changed to meet the ever-changing sensory needs of your students.
You are a 3rd grade teacher and you are transitioning your class from a reading
lesson to math lesson. Today we will (each day stretch breaks look a little different but still only take about one minute):

jump in place three times

reach to the ceiling then to the floor three times
close our eyes, think about the number 5 and take five deep
breaths (in through your nose, out through your mouth).

You are a secondary social studies teacher and are getting ready to hand out
the dreaded essay test! You tell the class that they have 45 seconds to stretch
and move. Ask them to

take three deep breaths

gather their thoughts.

Then (at teacher discretion) pass out gum, pretzels, or lollipops at the beginning of the testsensory input for improved attention/organization.



As you can see, the teacher-facilitated sensory and transition components

decrease dramatically as the student ages. The student is expected to develop
the skills and self-awareness that are necessary to achieve and maintain that
quiet alert state for optimal teaching and learning. Through awareness and
practice, most students will develop the ability to self-monitor. Self-monitoring doesnt necessarily happen because a student hits a certain age or grade.
Therefore, if you have a student, whether preschool, elementary, or secondary,
who is having academic or social difficulties, ask whether the students
self-awareness or self-monitoring skills are age-appropriate. If the answer is
no, could it be that the student has not developed the sensory/sensory-processing abilities to be successful? So, basically what we are suggesting is to
think out of the box and dont be afraid to try some new sensory strategies!

Modifying teaching and the curriculum

Before we look at specifically modifying the curriculum for a child with
sensory issues or sensory dysfunction, we feel it is important to take a look at
the overall developmental appropriateness of the program. This is particularly
important in early childhood programs such as daycare settings, toddler class,
preschool class, Universal Pre-K program, early elementary school program
or a before- or after-school program.
By developmentally appropriate program we mean a learning environment and activities that are based on knowledge of typical development of
children within the age range you are servingremember that developmental
timeline? The research we have seen indicates that most children who
progress within a range of slightly above or slightly below their chronological
age are still considered to be typically developing. Therefore, a developmentally appropriate program should be one modified to a childs unique
level and range of development in all areas. However, we do recognize that
there are children whose developmental age may be significantly below their
chronological age where a developmentally appropriate program may need
considerably more individualizing or adapting.
The good news is that many teachers are modifying the curriculum
already. But you may want to look a little more closely at your lesson plans, the
daily routine, and the classroom environment, whether you are a preschool
teacher, elementary school teacher, or secondary teacher. More good news, it
has been our experience that including sensory strategies may benefit most, if
not all, students. Lets begin by taking at look at modifying lesson plans.



The following steps will look very familiar to most teachers:

Step 1: Select the skill or subject area to be taught.

Step 2: Identify the specific skill or topic to be taught.
Step 3: Identify the curricular goal/objective.
Step 4: Create and develop a plan for instructional delivery.

In virtually every classroom, there are students who have difficulty participating or completing a lesson. Many times, these difficulties can be boiled down
to sensory/sensory-processing issues. As a teacher, you have already put a
great deal of effort into creating a dynamic, purposeful, engaging lesson/
activity. We are suggesting that you now take a look at this thoughtful lesson
plan and consciously be aware of the sensory componentsif it includes oral
direction giving and/or lecture (auditory), writing on the board/overhead/
powerpoint/handing out written instructions (visual), if there is a hands-on
element or a manipulation of something (kinesthetic), or if it involves numerical concepts/computation (math)you get the idea. Chances are, there are
some kids in your classroom who have difficulty with learning, comprehending, or processing. Typically there are also students in the class who present
with behavioral challenges who may, or may not, have learning difficulties.
So, what we are trying to illustrate is that:

there are children with behavioral challenges, but no apparent

learning difficulties

there are children with learning difficulties, but no apparent

behavioral challenges

there are children with behavioral challenges and learning


there are children who have no apparent behavioral challenges or

learning difficulties.

As teachers we would like to order 25 students from the fourth category for
the next school year, please!
What we are going to address next are some curriculum adaptations that
can be used to support students who present with behavioral challenges,
learning difficulties, or both. We want to make it clear at this point that we are
not suggesting that a teacher who has already worked hard to create a very
good lesson plan go back to the drawing board and create multiple lessons to



address the same objectives (we know how much time that would take!). What
we are suggesting is that there are strategies to help you get more bang for
your planning buck!
The following are some suggestions for additional ways to modify or
adapt the curriculum for a child with sensory dysfunction.

Timeconsider adapting the time allotted for learning and task


Sizeconsider adapting the number of items the child is expected

to learn or to complete.

Level of supportif possible, increase the amount of assistance

given to this child.

Participationconsider adapting the extent to which the learner

must be actively involved in the task.


The following is an example of how you can develop and implement a lesson
by incorporating sensory strategies to better meet the needs of your students.
Objective: At the end of this lesson, the student will be able to retell a simple
Here are some ways in which you may already be developing a lesson for
this objective.

Gather the kids in a circle, read the story and ask follow-up

Choose a book that has repetition built into it.

Encourage students to participate verbally during reading.

Utilize an over-sized book that incorporates textures and bright


Encourage students to participate through both words and


Now you can analyze how the children in your class participated/reacted to
this activity.
You may have a child(ren) in your group who:



just wanted to shout

got a little lost or appeared to be daydreaming

just wanted to stand there jumping (not appearing to listen)

frequently crawled across the circle (over their neighbors) to feel
the textures in the book

got too excited and started poking, prodding, or pushing their


From a sensory standpoint here are few thoughts.

For the shouter (possible auditory, impulsivity from sensory load):

Prepare the whole class, reminding them (auditory) to use an

inside voice during the participation part of the storypractice
once or twice (oral/motor).

Use nonverbal prompts such as gesturing quietly with

exaggerated facial expression (visual).

Give nonverbal visual feedbackwink, thumbs up, etc. (visual).

For the jumper (possible proprioceptive, vestibular):

Incorporate some type of music and movement activity as a

transition to the reading activity (proprioceptive, auditory).

Prepare and practice for appropriate participation (proprioceptive).

In our experience, kids who are moving excessively and frantically are not
easily able to respond to nonverbal/verbal cues, let alone attend to what you
want them to attend to. So, this is where you anticipate this response from this
child; you do your best to plan for it.

Have the child wear a weighted vest (with OT/PT consult).

Delineate space (tape, towel, rug, hula hoop).
Give the child something to squeeze (stress balls).
Teach the child ahead of time a modified jumpbending the
knees in place of a full jump (remember, it is about adaptive
responsessensory input will stimulate another sensory response).



For the toucher (tactile):

Make the child aware that there are different textures in the book
and that everyone will get a turn to touch after the story is
finished (auditory).

Give them something textured to hold while reading the story.

Give visual remindersstay on your mat.

For the dreamer (visual, auditory, or sensory overload):

Use the classroom FM system (auditory).

Arrange preferential seating (near teacher) (proximityaccess to all


Provide additional prompts (physical, visual, auditory).

Use auditory trainer (auditory).

Give a verbal prompt paired with a sign to redirect attention to
book (auditory, visual).

For the poker (auditory, visual, proprioceptive):

You need to prepare every single timewhen we listen to a story,

where do we need to be looking, who do we need to be listening
to, where do our hands need to be? (auditory, visual).

Create spatial awareness, delineate spatial boundaries

(proprioceptive, visual).

Use fidget toys (tactile, proprioceptive, visual, olfactory).

Use voice inflectionkeep reeling them back in(Oh boy,

look what happens now!).

Arrange preferential seating on the end, in the back, slightly


This is by no means an exhaustive list. There are many other sensory-based

strategies that you can implement, and may already be implementing. The
point here is to analyze what you are already doing, recognize the sensory
components, and start using them to your advantagenow you are beginning to get the bigger bang for your planning/management/learning buck
that we mentioned earlier!

Chapter 5

At Home and at School:

Looking at Strategies

Weve devoted a good portion of this book to recognizing and understanding

the very complex nature of sensory integration and sensory dysfunction. It is
our experience that many children with sensory issues or sensory dysfunction
tend to be emotionally labile, easily frustrated, and frequently exhibit behaviors that could be considered immature for their age. We recognize that being
a child with sensory issues or sensory dysfunction is often not easy, and can be
very isolating. And we understand that being the family member, the daycare
provider, or the teacher of a child with sensory issues may not be any easier. It
is our experience that developing an understanding and a willingness to try
different strategies is often very helpful.

Management techniques
One of the most important areas is communication with the child with
sensory issues. Here are some strategies that we have found helpful.

Gain your childs attention and make sure he or she is listening

before giving directions.

Turn down/off the TV or CD player, or ask others talking to

pause before giving your child directions.

Squat or bend down and ask your child to look at you to make
sure you have his or her attention before speaking.




Use natural gestures as visual cues, such as pointing or motioning

when you give your child directions.

Be sure to speak slowly and clearly.

Have realistic expectations for your childwhile chronologically

your child should be able to follow multi-step directions,
developmentally your child may simply not be ready.

Have your child repeat the directions back to you.

Repeat directions as needed.
Choose words carefullyonly use words your child understands
and keep the message short and simple.

We believe that most children have a strong sense of wanting to belong and
do a good job. Many parents, teachers, and other adults who are unfamiliar
with the concept of sensory issues or sensory integration dysfunction may
misinterpret a childs challenging behavior and react negatively. In many
cases this can lead to power struggles over a behavior that is misconstrued as
defiant, non-compliant, or attention-seeking. That is not to say that
children with sensory issues or sensory integration dysfunction never exhibit
typical behaviorsthey do! But it is our experience that frequently their
challenging behaviors tend to be sensory-driven.
Some of the behaviors sometimes seen in children with sensory issues and
sensory integration dysfunction that are frequently overlooked or misunderstood are self-calming behaviors. Some of these self-calming behaviors may

mouthing objects
kinesthetic movement
humming/mouth noises
visual self-stimulation
leaning up against things/seeking deep pressure
staring into space.



Since behavior is a means of communication, children with sensory issues and

sensory integration dysfunction who are exhibiting self-calming behaviors
are, most likely, trying to tell you somethingI am trying to organize my
sensory systems! Sometimes, parents and teachers, with the best of intentions, try to get the child to stop a self-calming behavior. For example, a parent
has a child who is humming constantly and no one in the family can hear the
television. The parent may insist the child stop humming only to hear the
child begin seconds later making a different mouth noise. Or take the 4th
grade teacher who has a student staring out the window in a fixed gaze
watching the trees blowing in the windthe teacher may decide to close the
blinds to make the student stop and refocus on the lesson, only to find the
student then staring in a fixed gaze on the classroom clocks second hand. Or
how about the parent whose child is mouthing on his shirt sleeve? The parent
insists the child stop because it is ruining the shirt; the child briefly stops
chewing on the shirt, but then begins chewing on the highlighter his sister
left on the counter while doing her homework. Or take the preschool teacher
whose student is leaning so hard into the shoulder of the child sitting next to
her at circle time that the child complains that it hurtsthe teacher reminds
all of the children to sit up nice and tall with eyes on the book, only to then see
the child slowly scootch backwards until she is across the room leaning
against a bookshelf.
Bottom line, if a child with sensory issues or sensory integration dysfunction is exhibiting a behavior that appears to be self-calming, and that behavior
is stopped, the child will most likely replace it with another, yet similar,
self-calming behavior. If the child is not allowed to do so because the
behavior is determined to be inappropriate or unsafe by an adult, the child
may have difficulty staying organized or calm, which may result in an even
more challenging, inappropriate, or unsafe behavior.

Helpful behavioral strategies

While prevention of challenging behaviors through a multi-sensory approach
is often best, the following are some behavioral strategies you may want to try
that we have found helpful.

Encourage the child to engage in a more socially appropriate use of an object

or a behavioral alternative. For example, when a preschool-age child becomes



upset because his brother is sitting so close to him that his arm touches his
(tactile defensiveness), becomes upset and begins throwing the blocks, say to
the child, Blocks are for building. Lets build with the blocks, while helping
the child physically distance from his peer so that their arms are no longer
touching. Or, if you are in Burger King and your child is refusing to stay
seated (sensory overload) you may want to consider taking your child (and
your food) and heading out to the car or a quieter spot to eat.

Here you demonstrate the behavior you would like the child to engage in. For
example, a parent might say to a young child, Please put your dirty dish in
the sink, while the parent is putting his or her dirty dish in the sink. Or if you
are feeling incredibly frustrated you could say something like: I am so upset
right now I could just screambut, I am going to calm myself down, take
three deep breaths, and regroup.

You could reinforce the behavior of another child who is engaging in the
behavior you would like the child to engage in. For example, you are going to
the store and you see a mother with two children entering, and both of the
children are nicely holding hands with the mother. You can just point out to
your children: Look at those kids, they are holding their moms hands. Thats
a safe way to walk through the parking lot. Wow, so when we walk in the store,
I want us to hold hands and be safe too.

These are statements that restate a naturally occurring, positive event to

prompt increased compliance. For example, a parent is trying to get a child
ready to go to an appointment. The child is refusing to get dressed and beginning to tantrum. The parent prompts the child by saying: If you get dressed
and we can get downstairs quickly, then you can have your breakfast sooner.
Or, for the older child who is having difficulty finishing the math homework:
If you finish your math homework, then you may take a break.

Prior to the child reacting with inappropriate behavior, the adult can prompt
the child toward a behavior that is more socially appropriate. For example, a



kindergartener is obviously frustrated trying to fit a peg into the pegboard.

The teacher may say: Ask for help.

Following an incident where a child has demonstrated some inappropriate

behavior, thrown something, wrecked his work or another childs work,
pushed furniture aside, etc., allow him or her some time to calm down. Then
help the child to find a way to make the situation betterput something
back, redo it, fix it, etc.

When a child is beginning to tantrum, and you determine that the source of
the impending meltdown is sensory related, calmly remove the child or the
object from the immediate environment to reduce or eliminate the sensory
offense. If you are unable to do this, at least validate for the child that you
know this sensory input is very difficult for him or her to tolerate. For
example, a teacher has observed that one of her 3rd graders has an overly sensitive sense of hearing and that his desk is very close to the electric pencil
sharper. The teacher also observes that every time someone sharpens a pencil,
this student yells. The teacher may decide either to move the child to another
desk or to move the electric pencil sharpener. This same student might be on a
field trip to a science museum where the docent shows the class a certain
machine by turning it onit is very loud. The teacher is unable to move the
child away from the machine due to the number of students in a small physical
exhibit space, but discreetly bends down and whispers in the childs ear: I
know this is hard for you to listen to.

This involves placing yourself near the child to serve as a prompt/reminder

for the child to maintain an expected behavior. For example, a 1st grade
teacher moves a childs chair or desk physically closer to the teacher so that he
can more easily prompt the child to maintain the expected behavior. This can
be helpful with the student with sensory issues or sensory integration dysfunction because the closer the eye the teacher has on the child the more likely
he or she is to observe sensory-based patterns of behavior and so address



Unhelpful behavioral strategies

The following are some behavioral strategies that, in our experience, are not
helpful for a child with sensory issues or sensory integration dysfunction.

This behavioral strategy is also sometimes called extinction. When the inappropriate behavior occurs, the parent or teacher does nothing, says nothing
about the behavior, and acts as though it never happened. In theory, a childs
behavior that is not given attention will eventually stop occurring. If the
behavior is the result of a sensory issue or sensory integration dysfunction,
planned ignoring will be, at best, ineffective.

This usually refers to the child being removed by an adult from a desired
activity for a period of time due to inappropriate behavior. If the behavior is a
result of a sensory issue or sensory integration dysfunction, the child may
fight the time out both verbally and, often, physically, in order to be able to
seek the desired sensory behavior. When this happens, a small inappropriate
behavior (pushing by a peer to get to a toy or activity) may become a large
inappropriate behavior (swearing at or purposefully pushing the teacher, or

Here the parent or teacher lets the child know that he or she is disappointed
with the childs inappropriate behavior. Unfortunately, while it is not supposed to be used, an angry tone often accompanies this behavioral strategy.
Many children with challenging behaviors resulting from sensory issues or
sensory integration dysfunction are not choosing the behavior, rather they
are driven to it by sensory needs or deficits. An adult (especially one with
whom the child feels connected) who expresses displeasure or becomes angry
may only make the child feel more anxious, resulting in the child being even
less able to cope with sensory input.

Following a childs inappropriate behaviors, a parent or teacher may sometimes give the child nonverbal feedback such as a slight shaking of the head or
another mild expression of disappointment which may be too subtle for the
child to notice. When the behavior is associated with sensory issues, as is often



the case for a child with an autism spectrum disorder, the feedback will
probably be lost. However, other children (perhaps with learning difficulties
and/or a mental health component) may have a heightened emotional reactivity to facial expressions and nonverbal cues, perhaps as a result of emotional lability, the child may over-react to the expressed displeasure by
becoming unglued, yelling back, running away, etc.

This refers to the blocking of a behavior or holding a child to stop a behavior

that could be dangerous to the child or others. In our opinion, this behavioral
strategy should only be used as a last resort when serious harm to the child or
another could occur. For the child with sensory issues or sensory integration
dysfunction this type of blocking or restraint may only result in the behavior

Preventive behavioral strategies

If you are looking to try to prevent as many inappropriate behaviors from
occurring as possible, it is important to understand why they may be happening in the first place. Unfortunately many parents and teachers of a child with
sensory issues or sensory integration dysfunction, and other adults with
whom the child may come into contact, have no idea why the child is misbehaving and may even ask him or her Why did you do that? Trust us, there is
always a reason for misbehaving and the child usually doesnt have a clue
why he or she did something.
We think it is important to mention that as you begin implementing different behavior strategies, remember to look for and acknowledge the
feedback you will get through the childs arousal state. This may include
changes in a childs emotional state, appearance (eye contact, skin tone,
excitement level) or behavior (aggression, regression).

Considering and modifying the environment

Before we look at ways in which the environment can be modified or adapted
for a child with sensory issues, it is important to identify what factors can be
inherently arousing or calming. Inherently arousing factors include:

loud, sudden noises and/or voices

strong odor(s)
fast movement/unexpected movement



bright lights, bright colors

light or unexpected touch
changes in temperature
background stimulation/noise
unpredictable events.

Inherently calming factors include:

soft voice
soft odor(s)
steady, expected movement such as rocking
low lights, natural light, muted colors
even temperature
minimal background stimulation/noise
predictable structure and routine.

Whether it is at home, daycare, school, or any other environment where a

child with sensory issues will spend time, it is important to take a look at the
environment. While it is not realistic to attempt to modify every aspect of the
environment for a childs sensory integration dysfunction, most times a little
additional awareness can go a long way. Sometimes, just some simple changes
in a home, school, or daycare environment can have a very beneficial effect for
the child. Here are some questions that may provide a helpful foundation
when assessing an environment.

Level of stimulationIs the level of stimulation too much or too

little for the childs sensory systems?

Level of structure and routineIs there enough consistency and

predictability? Is there too much?

Number of sensory activitiesAre there enough sensory activities? Is

there a variety of sensory activities? Are there so many choices it
is confusing or over-stimulating?

Types of colorsAre the colors bright? Are they muted? More

importantly, do they match the level of arousal of the child? A
child who has a low level of arousal may respond to bright colors



and become more alert, while a child who is over-stimulated may

respond to muted colors and become more calm.

Type of lightingAre the lights fluorescent? Are the lights

low-watt lamps? Is it natural lighting? Is it dark? Is it bright
sunlight? Ask yourself, is the type of lighting a good match for
this childs sensory systems?

Type of musicIf there is music, is it loud? Is it soft? Is it heavy

metal, soft rock, rap, classical, or new age? How are the
childs sensory systems responding to it? Some children with a
high level of arousal may respond to new age music or nature
sounds by calming. Some children with a low level of arousal may
respond to louder, faster music by becoming more alert.

Use of texturesWhat types of textures are in the environment?

(Consider carpets, furniture, etc.) How is the child responding to

NoiseIs there an area where this child can go to have some

quiet time if needed? What is the level of noiseif it is too loud
for this child, can something be turned down? Are some type of
ear plugs or ear protectors appropriate?

Types of aromasWhat scents do you smell? How many scents do

you smell?

Number of transitionsIs this an environment that requires the

child to transition from one activity to another? If so, how
frequently? How is the child prepared for any transitions? Are the
current methods of transitioning working? If so, identify what
they are so they can possibly be used in another setting. If not,
why not? What modifications or accommodations might be
helpful for this child during transitions?

Accessibility of adaptive equipmentIf the child uses any adaptive

sensory equipment as part of a sensory diet, is it available in this
environment? Is it available whenever it might be needed or only
at certain times? What equipment needs to be brought in to
modify this environment to help this child to be more successful?

AwarenessAre the people in this environment aware of the

childs unique sensory needs? If not, be clear on your reasons



why. If so, be clear on your reasons why. Are your reasons,

whatever they are, the most beneficial for the child? Do the
people in this environment have a clear understanding of any
modifications or adaptations this child may need? If so, are they
kept current? If not, is there a need to identify resourceswritten
or otherwise?
It is our experience that it is often easier to modify or adapt the environment
for a child with sensory integration dysfunction during the early years. There
is no doubt in our minds that necessity is the mother of all invention. For us,
both as parents of children with sensory needs and as teachers, the times when
things are really not working well are often the times when we are most open
to trying something different. The following are some suggestions or strategies you may want to try either in your home or in your classroom.

Visual barriersUse furniture to provide visual barriers to help

delineate where one area or activity needs to end and where
another area or activity may begin. For example, if there is a toy
that needs to stay in one area, such as the trucks staying in the
block area, then consider positioning the block shelf to help
create a visual barrier.

Visual cuesUse tape or some other marker to help delineate

where a child is supposed to be. For example, ribbon can be tied
onto the side of the grocery cart to give the child a visual cue as
to where he or she is expected to hold on to the cart. Or tape can
be used in a classroom to give children a visual cue as to where to
line up to leave the classroom. Many young children, especially
those with poor body awareness, may not know where to be if
asked to come sit in a circle or line up at the door.

Aroma therapyThere are many different ways to do aroma

therapylotions, plug-in scents, etc. that are now available in a
variety of scents in many stores. We have found vanilla to be
calming, lemon to be alertingfor mothers and teachers as well
as kids! Check it out!

Visual supportsLabels, pictures, picture schedules, social stories

all provide visual support to understanding language. These can
be very helpful for a child who is not certain what something is,
what it is used for, what is happening next, etc.



Predictable routineCreate as much of a predictable and consistent

routine whenever possiblenot rigidjust predictable. Notify a
child in advance of changes and keep visual support on hand as

Be prepared to take a break or leave the environment if necessary. Our experience is that once a child with sensory integration dysfunction becomes
anxious, agitated, or upset as the stress level increases, the language abilities
often decrease making it very difficult to talk through a situation or talk
down the stress level. Sometimes the child just needs to take a break from the
Another useful suggestion is to create a sensory bag or sensory basket
that can go from environment to environment with the childhome to
daycareto schoolto Grandmasto wherever! The idea is that if the
child starts to lose composure due to sensory input or overload, the sensory
bag can be accessed to use a sensory approach to help manage the arousal
state or behaviors. While each childs bag should be based on his or her individual sensory needs, here are some suggestions that may help you get started:

something to squeezestress balls, etc.

lotion with one of the more calming scents, such as vanilla

a washcloth or small towel to wipe off anger

a visual or auditory timer to guide a child to continue to use the

sensory activities until calmer

an oral/motor blow toy (like a whistle) with any ability to make

sound removed.

two footprints that can be put on the floor for jumping or


two handprints that can be placed on a wall as a deep pressure

push place

a write-on, wipe-off board and dry erase markers

an unbreakable mirror so the child can see his or her emotions
words or pictures to help the child begin to identify these



Whether you are a parent, daycare provider, or teacher of a child with sensory
integration issues, this sensory approach to behavior management can be
extremely effective. Our experience has been that while initially children may
need to be directed to use the sensory bag, they will soon be open to it as a
suggestion and may quickly gravitate toward using it independently. Why?
Because it makes them feel better and helps them regain composure using a
positive, proactive approach. The other aspect of the sensory bag that is
extremely valuable is that it will give those working or living with the child
valuable clues as to which sensory activities help the child to calm and
regroup. For example, if the child often chooses to blow on the oral/motor
toy then taking five deep breaths may work well as a calming tool. Or if the
child often chooses a deep pressure activity such as pushing the wall or
jumping or stomping on the footprints, then this may be a child who responds
well to heavy work as a calming tool.

Self-care strategies
For many children with sensory issues or sensory dysfunction, self-care skills
may range from challenging to aversive. Some children will have a heightened
sensitivity to sensory input; for others, it may be a decreased awareness of
sensory input. The following suggestions may be helpful.


An unbreakable mirror (with suction cups on back) to attach to

side of tub so child can see self while washing, shampooing, and
rinsing. The child is then able to anticipate when he will be

Consider allowing the child to do as much of the lathering/

scrubbing/rinsing as possible (this gives her a greater sense of
predictability and control).

Be aware of water depth (gravitational insecurity).

Make sure that you are real clear about the temperature regulation
(some kids will want to be polar bears, others may be in danger
of being scalded) (lack of temperature awareness).

Consider purchasing and applying an inflatable faucet cover to

avoid injuries, even if your child is older (poor body awareness).



Consider the level of stimulationamount of toys, noise level,

number of people in the bathing area (over-stimulation).

Consider covering the bottom of the tub/shower with a

rubberized anti-slip mat (coordination issues).

Provide verbal prompts as needed to support independent

bathing/showering (difficulties with motor planning).

Washcloth over eyes when shampooing/rinsing.

Soap on a rope/hand mitts (hand dexterity).


Try different textures and flavors of toothpaste.

Try different toothbrush shapes, kinds, sizes.
May need desensitization prior to brushing.
Parental follow-up may be needed even for older children.
A water pick instead of flossing.


Consider elastic-waisted pants (tactile, motor planning).

You may need to provide assistance with dressing for a longer

than expected period of time (fine motor, motor planning, etc.).

For some children too many choices may be overwhelming.

Try to be flexible with clothing choicesthere may be a sensory

sensitivity behind them.

Remove tags.
Buy seamless clothes.
Some children may prefer long-sleeved or short-sleeved shirts,
short or long pants regardless of season or may have difficulty
changing wardrobe from one season to the next.




Be aware of food temperature (may need food reheated or cooled


Be aware of texture preferences and aversions.

Allow for difficulty with manipulating eating utensils (use

weighted utensils, utensils with different grips,
drip-proof/spill-proof bowls, etc.).

Consider the visual presentation of food (colors, shapes,


Plan aheadthink about what types of food and drinks will be

offered and consider possible substitutions.

Keep in mind food may need to be cut up more, given in smaller


Monitor consumptionsome children will not feel full, some may

not feel hungry or thirsty.

Use verbal prompts for chewing, wiping face, etc.

Take into account any heightened awareness/lack of awareness of



Have a consistent bedtime routine.

Try calming music.
Try different lighting.
Use weighted blankets.
Experiment with different pajamasstyles and fabrics.
Allow time for reading/journaling.
Have things set out for the next day.

These are just some suggestions which you might find helpful. We have found
by sharing with others (parents, teachers, daycare providers, etc.) you will
discover additional strategies to try out and expand your list.

Chapter 6

More About Aspergers Syndrome

Recently, there has been a significant increase in the diagnosis of autism

spectrum disorders, especially Aspergers syndrome. This is becoming of particular consequence to the educational community and to teachers in general
education as well as in special education classrooms. The average age of diagnosis for Aspergers syndrome is currently six and a half years. This means that
for most children, a diagnosis may not occur until the child has been through
preschool and is into elementary school. Frequently, it is the pragmatic issues
(taking turns in conversation, voice modulation, interrupting, physical proximity, perseverating on a topic, etc.) and the sensory issues that create the red
flags for parents (and teachers) to seek out a diagnosis for the child. Children
with Aspergers do not outgrow their odd and quirky behaviorswhich are
frequently sensory driven.
The purpose of this chapter is to explain Aspergers syndrome in a
down-to-earth and easy-to-understand manner. Dealing with this enigmatic
disability on a day-to-day basis is a frustrating and daunting task. In the
interest of being efficient and practical, the rote, technical (impossible to
understand) definitions will be given first. In order to facilitate understanding,
the traditional definitions will be followed by examples and brief explanations. It is also intended to provide practical, effective strategies that may be
helpful for many children with sensory issues or sensory dysfunction.




Diagnosing Aspergers from the DSM-IV: Selecting from the menu

Okay, take a deep, cleansing breath and uncross your eyes. And if you understood any or all of the DSM-IV definition in Chapter 3, then either you are a
developmental pediatrician specializing in pervasive developmental
disorders, the parent of a child with Aspergers syndrome, or much too interested in medical terminology.
It is important to keep in mind as you read through this section of the
book, that Aspergers syndrome is truly part of a spectrum disorder; that is to
say that the symptoms can range from very mild to very severe. And, to add to
the confusion, the different symptoms within the same child may vary significantly. For instance, a child may have almost normal eye contact (mild gaze
avert), but have an extremely narrow range of interestshe will only talk
about dinosaurs. Or a child may have the vocabulary of an adult, but not be
able to comprehend basic directions and instructions given by a teacher or
Now we are ready to tackle each of the diagnostic criteria individually,
keeping in mind that each child is an individual and may exhibit characteristics anywhere along the spectrum, from mild to severe. Also, the diagnosis of
Aspergers syndrome is a clinical diagnosis, that is to say that the doctor (psychologist, neurologist) looks at the list of clinical characteristics and determines if the child has the symptoms, characteristics, and behaviors that match.
There is no biological marker or blood test to determine if a child has
Aspergers syndrome (or most of the autism spectrum disorders). The sections
that follow here correspond to the full text of the diagnostic criteria set out in
Chapter 3.

Qualitative impairment in social interaction


A child, Dan, is sitting in the classroom, looking at a book. Another child,

Kate, comes over and asks, What book are you looking at? Dan does not
respond, appearing to be engrossed in his book. Kate continues, Dan, can I
look at the book with you? At this point, Dan, without looking up, says,
Ok. Kate proceeds to sit down next to Dan.
Kate then asks Dan if she can hold the book for a while. Dan hands the
book to Kate. Kate opens the book, placing half of the book on her knee, and
the other half on Dans knee. Kate browses the pictures and reads the text. But



as she does so, she glances furtively over toward Dan, asking, Are you ready
for the page to be turned yet?
In response to Kates question, Dan grabs the book and turns to the back
of the book, stating, without looking directly at Kate, This is my favorite
page; it has the most question marks on it. I like question marks.
Overtly, this may be an exchange that teachers, particularly preschool and
early elementary teachers, witness on a regular basis. Dan is acting aloof, but
seemingly within the boundaries of what would be considered developmentally appropriate. However, if we analyze this exchange, a pattern begins to be
Lets look at the nonverbal social interactions from this scenario. Kate is
reading the nonverbal cues. Dan seems engrossed in a book so she asks to
join him. She looks over to Dan for clues that he may be ready to move to the
next page; when she does not get any nonverbal feedback, such as Dan
looking over to her, or away from the page, Kate finally asks Dan.
Conversely, Dan appears to totally disregard most of Kates nonverbal
cues. Notice that Dan did not even acknowledge Kate (verbally or through
body language) when she sat down next to him. Then, when Kate asks to read
the book with him, Dan responds by wordlessly shoving the book into Kates
hands. Additionally, instead of turning to the next page, Dan simply flips to
his favorite page and expects Kate to be enthusiastic about the shape of
question marks. Children with Aspergers are masters of the non-sequitor!

It is lunchtime in a nondescript elementary school. All the 5th graders troop

to one table to eat, the 4th graders to the next table, and so on. At the 5th
grade table, the boys sit at one end, eating quickly and dividing themselves
into teams, so they can play football with Mr. Hutchinson as soon as they get
to the playground. However, one child, Dustin, is sitting in the middle of the
fray eating and talking to the monitor about his science project.
The bell signaling recess rings, and a happy, energetic throng quickly
streams out of the cafeteria and onto the playground. As usual, a group of 2nd
and 3rd grade children begin a game of tag. The 4th grade girls jump rope,
while the 4th grade boys play football. The 5th grade girls join in the jump
rope game or roam the playground in groups, giggling, laughing, and
watching the boys play football. The one notable exception to the daily play-



ground rituals is Dustin, the 5th grader, who refuses to play football with the
other boys, but instead happily plays tag with the 3rd graders.
This is one of the hallmarks of the Aspergers child: tending to get along
well with adults, but prefering to play by himself, or with children who are
much younger. Any of the typical 5th grade boys would be mortified to be
caught playing tag with the 3rd graders or to spend their lunch conversing
with the monitor! These are the kids that just dont seem to have real friends:
peers that want to come over to play, and who are, in turn, invited to the
friends house to play. Often what happens is that the parent becomes worried
when the child has friend after friend over, only to find out that none of
these friends wants to return for a second time. Frequently, the child who has
Aspergers (and the parents) is left devastated and frustrated. The bottom line
here is that the child has difficulty developing and maintaining meaningful,
reciprocal friendships.

The entire kindergarten class was mesmerized. Choruses of ooing and

ahhing were punctuated by shrieks of delight as the children watched the
magician perform the opening portion of his act. The teacher noticed that all
of the children pointed in unison when the magician asked where the colorful
flowers had disappeared to, or when the dove flew into the hat. All of the
children, that is, except David. A little taken aback, the teacher stopped and
thought for a moment; David never really seemed to point, even when he
wanted something! All year the classroom aide had joked that her arms had
lengthened by three inches from Davids constant tugging and pulling to
show her things. In this instance, David is not interested in sharing the groups
excitement about the magician, but may demonstrate excitement when a
classoom guest discusses a topic that is more closely aligned to Davids
personal interests.
As with any of the characteristics of Aspergers, the manifestation can
range from mild to extreme. On the mild side for this characteristic, is the
child who seems very pleased with her accomplishments or finished projects,
but appears to lack enthusiasm for showing her work to others (even her
teacher or parents). This often leads the adults to view the child as shy or
lacking in self-confidence. On the extreme end is the child who rarely points
to a desired object, but instead will stand in front of the sink if he wants a



drink of water, or walk over and stand beneath the letter A if that is the
answer to the teachers question.

James is a bright, attractive 2nd grader. He is beyond himself with excitement

because today a classmate, Steven, is coming over to play. James has been
eagerly anticipating Stevens arrival, making sure that all of his action figures
are properly laid out on his bedroom floor. Finally the doorbell rings! James,
smiling broadly, grabs Steven by the arm and starts pulling him toward his
bedroom, chattering anxiously about his action figures.
Steven happily plays with James and his action figures for over 45
minutes. Then Steven asks James if he has any other toys or games. James nods
toward a huge toy chest and shelves. Steven goes over to the toy box and finds
a very cool Lego set.
Hey, James, lets build a haunted house!
James shakes his head, No.
Okay, then how about we race your remote control car? Again, a very
uninterested James says no.
How about Nintendo? queries Steven.
Finally, Steven gives up and trudges down the hall to Jamess mom. I
think I want to go home now. James only wants to play with his action
Jamess mom quickly calls James over and tries to cajole him into playing
some other games. Honey, Steven is your guest and he wants to play something else for a little while. James, how would you feel if you visited Steven
and he only wanted to play with his Nintendo? Come on, James, it will be fun
to play a different game for a short time.
Steven leaves while James remains happily in his room, playing with his
action figures.
In this example, James is like most other children his age in many respects.
He is very excited about having a classmate over for a play date and he wants
to play his favorite game first. However, it is his inability to comprehend emotional or social reciprocity that makes James stand out. While it is normal for a
child this age to not have a complete handle on the idea of sharing and reciprocating, Jamess actions and responses are too rigid. By this age, most
children are able to understand basic manners and polite sharing. In this situation, it is evident that, even though James desperately wanted Steven to come



over and play, James does not comprehend the rudimentary elements of turn
taking, and is not able to understand Stevens perspective at all.
These are the students in the classroom that may appear to have a unique
sense of justice which is driven by their egocentrism. As far as they are concerned, it would be perfectly acceptable for them to be line leader or messenger every day; but it would not be fair if another child were line leader
or messenger every day.

Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities

For a diagnosis of Aspergers, this needs to be manifested by at least one of the

encompassing preoccupation with one or more stereotyped and

restricted patterns of interest that is abnormal either in intensity or

apparently inflexible adherence to specific, nonfunctional routines

or rituals

stereotyped and repetitive motor mannerisms

persistent preoccupation with parts of objects.

We want to emphasize here that although only one of the aforementioned

attributes is needed as part of the criteria for diagnosing Aspergers syndrome,
many children with Aspergers will present with more than one of these characteristics. And again, this is a spectrum disorder, so while one child will
present as always and intensely a certain way, others may present as
behaving that way at times.
Roberto is a bright and energetic six-year-old. He is also the resident expert
on dinosaurs at Little Elms Elementary School. Roberto impresses most of the
children and all the adults in the building with his in-depth and comprehensive knowledge of dinosaurs. Virtually all of Robertos clothing and school
gear are dinosaur themed, right down to his underwear and socks! In fact,
Roberto is so excited about dinosaurs that he able to focus on little else. All of
his conversations quickly revert to dinosaurs, and he becomes visibly upset
when asked to talk about something else. What was at first an endearing trait
rapidly lost its allure as Robertos teacher and classmates hear the same facts
about dinosaurs, over and over again, on a daily basis.



Many young children are interested in dinosaurs (or trucks or Thomas the
Tank Engine), but children with Apsergers often differ in the quality and
intensity of their focus. Like Roberto, the topic of interest typically does not
lead to reciprocal conversational exchanges. The child is repeating facts,
regardless of whether it is an appropriate time to relate such information or
whether the people around him care to hear the information.
Tariq is a 3rd grade student who daydreams and appears to be quite anxious
about ridiculously mundane aspects of the class schedule. Every day, Tariq
asks if his mother is going to pick him up from school or if he is going to ride
the bus home. Tariq has ridden the bus home from school every day since the
first day of school; once and only once has his mother picked him up for an
early dental appointment. The teacher has come to the conclusion that Tariq is
truly upset until he hears an adult tell him that he is, indeed, riding the bus
home after school today. Tariq also becomes unduly agitated if the class does
not leave for physical education, art, or lunch at exactly the time they are
supposed to leave; if art is at 10:45, then leaving at 10:47 will most likely
cause Tariq to cry or start his worry fingers (clasping and unclasping his
fingers into fists, as if he is squeezing an imaginary tennis ball). The teacher
often wonders if Tariq receives enough attention at home from adults, or if he
gets too much attention and is babied.
In this example, Tariq is genuinely disturbed by the most subtle changes
in his routine and is quite inflexible about time and scheduling. He appears to
be in an anxiety and adherence-to-routine loop with his daily preoccupation
with how he is going to get home.
Terrance is a handsome and placid 1st grader. In fact, Terrance is so laid
back that the chaos at recess and free play never seems to bother him.
Terrance can usually be found in a corner, or even amidst the fray, lining up his
matchbox cars and concentrating on watching the wheels spin. Sometimes,
Terrance sits at the computer and presses the same button over and over
againhe loves to see the cat jump over the mouse!
Many children in the 1st grade, particularly the boys, will play with cars
or movable toys whenever they are given free choice. Likewise, children
tend to relish time at the classroom computer. However, it is the quality and
duration of Terrances play that make it significant. Terrance is preoccupied
with a part of an intended play object or learning tool. He is not playing



together with other children or attempting more sophisticated (or even different) play activities.

Clinically significant impairments in social, occupational, or other important areas

of functioning
In all of the aforementioned examples, the children are viewed by their peers
as social misfitsor at the very least, socially very odd. Children with
Aspergers generally want friendships, but do not have the social skills or
social savvy to create and maintain a friendship. Frequently, children with
Aspergers are very socially immature, socially aloof, or downright little dictators. Typically, students with Aspergers are not easily integrated into peer
groups and present with social (and behavioral) challenges when the class is
required to participate in cooperative group activities. The student with
Aspergers will lack the social and communication skills to work easily or
effectively in peer group situations.

No clinically significant general delay in language

When Kwang was three years old, his grandfather gave him the nickname,
Professor Kwang after demanding a citrus fruit and a protein for a snack.
Soon the whole family began referring to Kwang as PK. PKs vocabulary
was amazing. His preschool teacher marveled at his ability to tell adults about
his intricate fantasy world. However, by the time PK was in 6th grade, his
parents and teachers were exasperated and perplexed by his inability to hold a
reciprocal conversation with his peers. PK was certainly still a little professor with an extensive vocabulary and a voracious appetite for comic books,
but he constantly interrupted, talked off topic and never actually listened to,
or looked at, the speaker!
PK is a very familiar example of a child with Aspergers, who, when he is
young, dazzles people with his vocabulary and intelligence, but as he grows
older his difficulties initiating and holding a conversation (the pragmatics of
language) become increasingly more pronounced, leaving him socially

No other clinically significant developmental delays

Jevon had always been described as bright, but a little bit odd. He walked
early, talked early, and was able to feed himself and dress himself as well as any
other child his age. Now, at the age of ten, Jevon is a dreamer who excels at



video games and swimming. He loves going on vacations to the beach with
his family, as long as he has his stash of Chips Ahoy cookies and his Game Boy
with him. Jevon can certainly be described as emotionally and socially
immature, but doesnt that describe a lot of boys his age?
Now, this is why we refer to Aspergers syndrome as a package deal. A
child (or adult) who has Aspergers is not defined by a single attribute, but
rather by an inventory of behaviors and characteristics that must be assessed
as to how (qualitatively) they combine to affect the child (or adult). However,
to have a bonafide diagnosis of Aspergers syndrome, a child must have at least
average cognitive abilities (though many children with Aspergers fall into the
gifted range of cognitive abilities).

No diagnosis of another pervasive developmental disorder or schizophrenia

A certified developmental pediatrician, child psychiatrist, child psychologist,
pediatric neurologist, or general pediatrician must have extensive developmental background information, as well as an in-person interview, to assess
whether a child has Aspergers syndrome and to rule out other autism
spectrum disorders and other conditions that may manifest similar characteristics or behaviors. Again, we must emphasize that Aspergers syndrome is a
package deal, so the child must actually been seen in person by the
professional rendering the diagnosis.

Social and communication deficits: Pragmatics made easy

Pragmatics are the cornerstone of our social language and the key to understanding the deficits in communication that children with Aspergers
syndrome experience. It is essential for every parent and every teacher to have
a basic understanding of the components of pragmatics because pragmatic
difficulties appear to be the common, rogue thread running through the core
areas of impaired social skills and a lack of meaningful, reciprocal communication. Simply put, understanding pragmatics will give a parent or a school
professional the foundation upon which to devise concrete strategies to help
the child with Aspergers function more easily and with much less frustration in
school, at home, and out in the community.
It is important to note here that one of the defining characteristics of a
child with Aspergers syndrome is that he or she will possess superficially
normal language. That is precisely why it is so important to understand the subtleties of social language and communication. However, one caveat here:



this section divides pragmatic speech into discrete component parts and discusses each part individually, in isolation from the rest. In reality, of course, all
of the component parts occur simultaneously to produce the real pragmatics
of speech. We will now look at the following components of social
communication in turn:

pedantic language
difficulty taking turns
interrupting conversations
difficulty with voice modulation
odd prosody
inappropriate or absent voice inflections
difficulty staying on topic and responding appropriately
difficulty with facial cues and body language
gaze avert
narrow range of interests
literal interpretations
difficulty generalizing information
physical proximity issues.

Pedantic language
Pedantic language is what most of us consider to be the little professor
vocabulary and grammar. Children with Aspergers will often use big vocabulary words and very formal sentence structure and end up sounding like
mini-adults instead of children.
The average five- or six-year-old might say that he wanted a cookie when
asked what he wanted from the bakery. A five- or six-year-old with Aspergers
might say something like, Id prefer a cake-like confection. I once overheard
a group of 4th grade boys bragging about how fast each could run: Im the
fastest runner here! the first boy proclaimed. Are not, Im way faster than
you, chimed in the other three boys, simultaneously. As the four boys
volleyed are not and are so back and forth a few times, a classmate, who
had been standing near the group, playing with a video game, said loudly,



Jenna is the student in our class who is most fleet of foot. However, Mike L. is
the swiftest runner in the entire 4th grade.
A typical middle school student might say that the kids in his class acted
badly for the substitute, goofing around, not listening and talking too much.
A middle school student who has Aspergers might say, the students took
advantage of the substitute today, most of them were behaving obnoxiously;
talking back, making irritating noises and being very noncompliant.
Many children have extensive vocabularies, but will not engage in such
formal usage in daily situations. Of course most of the typical children in the
previous examples knew what the big vocabulary words meant, and quite
likely use such formal language structure and vocabulary when writing school
assignments, but would not speak like that in front of their peersit would be
too weird and adult-like!

Difficulty taking turns

Difficulty taking turns in conversations is by no means a trait reserved exclusively for a child who has Aspergers. Many children, particularly younger
children, seem to take a little while to get the hang of taking turns in a conversation, just like it takes time and maturity to learn to take turns while playing a
game. However, a child who has Aspergers will not naturally mature into a
reciprocal conversationalist, the same way that a typical child will.
The students in every 1st grade classroom spend a great deal of time
learning the art and science of turn taking. Turn taking is woven into every
activity throughout the day. First graders learn to take turns speaking, using
toys, playing games, completing work, eating, using the restroom, being
first, asking questions and lining up. However, by the time children are in
the upper elementary and middle school grades, most are relatively self-regulating as far as turn taking is concerned. Most conversational exchanges inside
the classroom, in the cafeteria, on the bus, in the hallways, and on the playground are free flowing and dont require a referee to keep track of whose turn
it is to speakthe rules of conversational turn taking have, in essence,
become internalized.

Interrupting conversations
Interrupting conversations is a hallmark of the child with Aspergers. As with
the turn-taking protocols that most typical children learn to internalize, the
dont interrupt rule seems to be very difficult for the child with Aspergers to



grasp and master. Again, most typical children will learn interruption etiquette rapidly as they grow through each school year. For example, most
kindergarteners (at the beginning of the school year) will interrupt anyone at
anytime. Yet, by the end of the school year, most kindergarteners know to
raise their hand and wait to be called on and not to interrupt a classmate or
adult who is speaking unless it is something very important (like the principal
is entering the room or the hamster got out of her cage). By the late elementary grades, most students will become annoyed with a classmate who constantly interrupts or inappropriately speaks out of turn. However, a middle
school student who has Aspergers is very likely to interrupt constantly and
inappropriately, seeming much more like a considerably younger student.

Difficulty with voice modulation

Voice modulation difficulties tend to be quite obvious, and, for the most part,
very irritating. Again, most typical children will learn quickly that they need
to adjust their voices to match the situation at home or at school. For
example, in school a quiet voice is used for library and testing situations.
There is absolutely no talking or noise making during a fire drill, a loud voice
is usually fine on the playground during recess, and each teacher will tolerate a
certain noise level in the classroom during group projects and transition times.
At home, shouting may be allowed while playing outside, but never at the
dinner table or while someone is sleeping. And, just like in the classroom, each
household has a noise level that is acceptable for various family activities, such
as watching television or playing a board game.
Unlike their typical peers, children with Aspergers may have great difficulty being able to adjust voice decibel levels to match the activity that they
are currently engaged in. Most of us know a child who only has two voice
levels: loud and off or barely audible and off.

Odd prosody
Prosody is basically the rhythm, pitch, and tempo of a voice. While each
person has a voice that is as unique as fingerprints, many children with
Aspergers will have a very odd or strange prosody in their voices. Typically, a
child with odd prosody may have a voice described as a high-pitched
sing-song voice, a monotone voice, a computer-generated voice or a
cartoon-like voice. Often a child with Aspergers will have such a strange or
offbeat cadence that it may seem as if he or she is speaking with a foreign



Inappropriate or absent voice inflections

Voice inflections while reading and speaking are essential to give meaning to
what is being said. Consider these sentences and how the meaning and intent
of the sentence changes when a different word is emphasized.

He said you took the car.

He said you took the car.
He said you took the car.
He said you took the car.
He said you took the car.

As children learn to speak, and then read, they learn to raise the pitch of the
voice at the end of a question (whether reading or talking conversationally).
This raise in pitch tells the listener that it was a question and not a statement or
an exclamation.
It is virtually impossible to discuss inflection without including prosody
in the discussion. Most typical children already have conversational inflections (as opposed to reading) mastered by the time they enter school. A child
with Aspergers who speaks in a monotone or sing-song voice and whose
voice inflections are either absent or inappropriate, will have a hard time
getting others to understand the intent of his or her words. Right now, go back
a couple of paragraphs and reread, aloud, in a monotone or sing-song voice,
that same sentence without emphasis or inflection. What a nightmare for the
listener and for the speakerWhat did you mean to say? What were you
attempting to communicate? How is the listener going to interpret what you
just said? You were using all of the correct words, in the correct order for
meaningwhy all the confusion?

Difficulty staying on topic and responding appropriately

Difficulty staying on topic occurs, in varying degrees, to most preschool and
early elementary children. The art of staying on topic increases rapidly as
children are exposed to the social etiquette and structure of a school day
(during reading circle, we talk about the book the teacher is reading, not
about our cat throwing up last night). By the time typical children enter the
late elementary grades, they will be conversationally on topic most of the
time inside and outside of school. Certainly by middle school, they will find
the person who is off topic in conversations to be odd. Middle school is also



the time when many children become aware of the time-honored manipulation of intentionally encouraging a teacher to go off topic onto a tangent, so
that material will not be covered and an assignment or test may be delayed!
A child with Aspergers will almost always have difficulty staying on
topic, or at least responding appropriately to the content of the conversation. Whether
or not a child remains on topic is quite obvious to the listener; responding
appropriately to a topic can be more of a qualitative issue. A typical child in
3rd grade might talk about her aquarium when the class is discussing a science
unit dealing with animal habitats. An aquarium would certainly be considered
a habitat for her pet fish. However, a 3rd grader who has Aspergers (and an
intense interest in bacteria) might talk about how high humidity affects
bacteria growth in the Amazon rain forest.

Difficulty with facial cues and body language

Difficulty recognizing and responding to the facial cues and body language
of others is a major stumbling block in understanding the social world around
youat home, at school, and out in the community. Typical toddlers understand the basic facial expressions of the people around themthey know by
looking at Dads face and hearing Dads tone of voice whether Dad is happy,
sad or mad. A kindergartener might offer a hug to a friend who is frowning
and tearing up. Most 1st graders certainly know when a teacher lifts her index
finger to her mouth and says shhhhh, then folds her arms across her chest,
that the class needs to quiet down right now!
In contrast, an 11-year-old who has Aspergers may be completely oblivious to (or confused by) facial expressions and other body language: unable to
differentiate between a frown and a grimace; unable to decipher the body
language that would warn a typical peer that the teacher is about 30 seconds
away from giving the whole class detention, so now would not be a good time
to complain about the kid sitting behind you touching your chair with his
A teenager who has Aspergers would most certainly be overwhelmed and
confused by the rituals and nuances of flirting, dating, and socializing. Such
an inability to correctly read body language and facial cues often leads to an
intense sense of frustration, depression, and anxiety. All too frequently, teenagers with Aspergers become socially isolated and potentially suicidal.



Gaze avert
Gaze avert has a very wide range of dysfunction, from very mild gaze avert to
complete gaze avert and everything in between, including intermittent gaze
avert and situational gaze avert. A child of any age with Aspergers may not
even face the person whom he is addressing, let alone look that person in the
eye. A student with Aspergers may have wonderful eye contact when she is
answering a math problem, but may have very noticeable gaze avert during
transition times.
A typical child learns quickly that you need to look at the person you are
speaking to, and, conversely, that people look at you when they speak to you.
Parents and teachers will often watch for degree of gaze avert when attempting to unravel the cause of a disagreement or fight (Johnny, look at me. Did
you call Dan a name?). A child who has Aspergers may or may not look,
regardless of guilt or innocence in such a situation.

Narrow range of interests

Narrow range of topics of interest is another hallmark of Aspergers
syndrome. Again, this is a qualitative issue. Typical children of all ages may
become enamored with a sport, hobby, cartoon character, or theme (e.g.,
trucks, Barbie dolls, dinosaurs). The three- through six-year-old set is particularly notorious for taking on a character or a theme and spending a large
amount of time somehow involved with the specific theme. Many girls and
boys seven through teenage years become very interested in a specific sport or
hobby or musical group. Most of us can remember the phases (as our parents
referred to them) we went through growing up Your brother just lived and
breathed for Little League baseball and the New York Mets, Remember that
summer that you learned to play the guitar? You spent every waking moment
playing that thing!
On the other hand, the area of interest for a child with Aspergers takes on
a whole different quality and intensity than that of a passing phase. Sure, my
brother, at nine, could give you all the names and statistics of the entire Mets
roster, but he was also able to hold conversations that did not revolve around,
or revert back to baseball. My brother was also interested in doing other
things, too. He certainly loved baseball, but an opportunity to go swim at the
local pool or go to a movie was never turned down. In fact, his best friend did
not share a love of baseball, but they remained best friends, always talking
about and doing other things in which they shared a common interest.



A nine-year-old with Aspergers and an intense interest in baseball will

have a wholly different tone and intensity for the subject. For a child with
Aspergers, virtually all conversations would revolve around or go immediately off topic to the subject of baseball. Baseball would be watched constantly, talked about exclusively, and thought about incessantly. The same
baseball-related facts would be repeated time and time again. It would be very
difficult to convince the child to engage in other activities.
Nevertheless, children with Aspergers frequently do change areas of
interest as they grow older. For example, Pollys son started out at age two
with an intense interest in garbage trucks and heavy equipment, at about the
age of four he became obsessed with Thomas the Tank Engine, then at age six,
his only interest was Batman, then at age nine, he was consumed by an interest
in Ninjas and learning the Japanese language. Now, at thirteen, he is trying
desperately to fit in with his peers, so he has learned the rules and statistics
involved with the National League Football, and learned the lyrics to several
heavy metal rock songs. (I questioned him about the songs and he was very
clueless about the meaning of the lyrics, but stated tearfully, All the kids in my
grade know these songs and I look like a geek if I dont.) He has learned
about these topics to fit in better with his peer group, not because of an intense
interest of his own. My sons true obsession now is a specific video game and
Jackie Chan, but he is aware that his peers consider too much an interest in
these topics to be weird or geeky.

Literal interpretations
The literal interpretation of conversations and written materials is very problematic for children of all ages who have Aspergers syndrome, as are idioms
and figures of speech. A typical seven-year-old knows that the expression its
raining cats and dogs means that it is raining heavily. A seven-year-old who
has Aspergers is likely to look out the window and expect to see cats and dogs
falling from the clouds. Likewise, a ten-year-old who hears his father say, Im
so mad I could spit nails, would realize that his father was expressing his
anger. A ten-year-old who has Aspergers would most likely step back and
wait for the nails to fly out of his dads mouth.
A child with Aspergers lives in a very concrete world, where words mean
what they mean; implied meanings, figurative language, idioms, clichs, and
abstract concepts are not easily recognized or readily understood. Many
children with Aspergers are quite good at understanding literal language and



deriving factual meaning from what they read. We call it the Dragnet
FactorGive me the facts, maam; just the facts. Most children who have
Aspergers will, from a very early age, repeat rote facts ad nauseam. A 2nd
grader who has Aspergers will, most likely, be able to answer any factual
question about a story they have just finished reading. However, the moment
the questions (about the same story) become interpretive and require
inferencing and critical thinking strategies, the student who has Aspergers
will be close to clueless. For example:
Andy jumped up and down, pounding his fists on the table. Cake NOW, Andy yelled as
he threw the plate of vegetables on the floor.

What did Andy want?



How was Andy feeling? How do you know?

Mad, because he was jumping up and down, pounding his fists
and yellingthings people do when they are mad.

A typical 2nd grader would be able to answer both questions, giving appropriate reasons for the response. On the other hand, a 2nd grader with
Aspergers would be able to answer the first, factual, questionAndy wanted
cake. But the second question would be much more difficult. The most likely
response would beAndy felt like he wanted cake, but not his vegetables.
Because the sentence did not come right out and say that Andy was mad,
interpreting the information in order to come to that conclusion is a very
complex and difficult task for a child who has Aspergers.

Difficulty generalizing information

Difficulty generalizing information or process from one situation to another is
also a hard task for a child with Aspergers. A typical eight-year-old will be
very comfortable ordering food from a McDonalds or a Burger King or a
Wendys. However, even though the process of ordering food at a fast food
restaurant is virtually the same for each restaurant, an eight-year-old with
Aspergers might not be able to generalize that process from one restaurant to
another. Each fast food restaurant looks different, has different names for the
meals (and combinations of meals, as my son has pointed out to me), and the
employees wear different uniforms. How many times has a teacher heard from
a parent that her child can do a task at home without help, while the child is



unable to perform the same task at school (or vice versa)? For a child who has
Aspergers, getting dressed, eating, ordering food, or doing a worksheet may
not generalize easily from one environment to another. This may often give
the erroneous impression that the child is simply willful and noncompliant
He can do it (dress, order food, complete a task, etc.) when he wants to, but if I
ask him to do it (at home, at school, at Grandmas etc.)

Physical proximity issues

All children have an invisible comfort zone that surrounds them. Typically,
younger children tend to be less aware of each others space and may unwittingly infringe upon a classmates physical comfort zone (Mrs. Smith,
Bradley is too close to me again! His foot is touching mine!). As they grow,
children rapidly become aware of the rules of conversation. One of these
rules is that a person does not stand on top of a classmate, or get directly into a
friends face when conversing with that person.
However, a child who has Aspergers may not only violate this rule when
talking to others (too close, too far, facing away), but may have a set of distorted rules concerning his or her own personal comfort zone. Every teacher
has had a child who cannot keep his hands to himself in line, but will tearfully
proclaim that classmates are pushing and hitting him when he has not
been touched! Many a parent of a child who has Aspergers has dreaded the
long ride to Grandmas, or the short ride to the grocery store because a sibling
will inevitably cross an imaginary boundary or the child with Aspergers will
have his hands all over his sibling, completely ignoring the siblings personal
space. In short, there will be no peace in the vehicle!
Thus, pragmatics are huge pieces of the Aspergers puzzle. Think for a
moment about the child in the classroom, who talks in that weird, monotone
voice, who always seems to be talking loudly to no one in particular, and interrupts constantly to talk (off topic) about carnivorous plants!

Colins day
The following is a glimpse into a day in the life of an 11-year-old boy, Colin,
who has Aspergers syndrome. The pragmatic speech elements of Colins day
will be identified.

Colin wakes up, uses the bathroom and starts to get dressed.



Colin bounds into his parents room without knocking (difficulty
generalizing process; only remembers to knock if it is night time and dark
outside). Colin proceeds to go over to his mom, and speaking very loudly
(voice modulation) in his monotone voice (prosody), asks her, Mother, has my
gray polo shirt been laundered recently? Or should I select a different shirt?

Colin gets dressed and goes downstairs.

Colins mom asks him if he wants cereal or waffles for breakfast.
Colin responds by perseverating (to continue a particular thought pattern
regarding a specific topic without the ability to shift easily to another topic)
on the gray shirt. Mom asks Colin again; this time Colin, who now is on the
other side of the room with his back turned toward his mom, responds by
screaming, Waaaaffles! (gaze avert, physical proximity, voice modulation).
Dad asks Colin and his older brother, Brad, if either of them want
a ride to school today. Brad immediately says Sure!, while Colin doesnt
respond at all (not reciprocal). Dad and Brad start talking about Brads camping
trip this weekend with his scout troop. Colin interrupts Brad mid-sentence and
says: The cafeteria is serving pizza for lunch today, so Im buying (off topic).
Brad rolls his eyes, sighs loudly and looks exasperated. Colin continues: I will
only buy on days when the cafeteria serves pizza or chicken nuggets. Today
Im buying because pizza is being served (not taking turns, not reading facial clues
and body language, off topic).
Dad drops Colin and Brad off at school. A classmate, Jake, greets
Colin with a head nod and a Hi, Colin. Colin softly says, Hi, Jake after he is
about ten feet past Jake (proximity, gaze avert, voice modulation).
The bell rings and Colin heads off to his classroom. Colin stands
in front of his locker, slowly taking things out of his knapsack and getting a
stack of books ready for morning classes. Colin appears to be completely
unaware that he is blocking the locker next to him, even though the lockers
owner is standing next to Colin, saying, Ahem, excuse me, ahem while he
taps his locker and swings Colins locker door back and forth (not responding to
body language or verbal clues).



Colin sits at his desk in homeroom, staring out the window
(normal 11-year-old behavior!). Jake and Nasean are chatting quietly about the
most recent action/adventure movie that they both want to see. Nasean asks
Colin if he has seen the movie yet. Colin replies, No, but Im going to test for
my red belt in karate in six months (not responding appropriately to content of conversation).
Colin sits in science class, listening to Mr. Zurich explain friction.
After a few minutes, Mr. Zurich asks, Who wants to see the rubber hit the
road? Colin is stymied and looks out the window toward the road (literal
11:05am Colin, Ashly, Henry, and Rajay get together, as instructed, to
work cooperatively on their Global Studies project. Colin forgot his portion
of notes and drawings in his locker (executive functioning). Henry, Ashly, and
Rajay stand around Henrys desk, looking at Rajays sketch of the diorama
the group will make. Ms. Clifton walks by and asks Colin (who is standing
about five feet from his group), Did your group banish you to the cheap
seats? Ms. Clifton realizes that Colin just doesnt get it (use of idiom/physical
proximity) and rephrases more literally, Does your group want you to stand
that far back? Colin then walks over to Rajay and stands practically right on
top of him (physical proximity). Rajay shoots Colin a look. When Colin does
not move away (difficulty interpreting body language), Rajay, exasperated, gives
Colin a gentle shove and says, Give me some space, dude. Colin is bewildered. Ashly rolls her eyes and asks, Lets just move along. This diorama
could actually be really cool.
12:15pm Colin lurches through the lunch line with the rest of the 7th
grade, bumping into the person in front of him two different times (physical
proximity). The server recognizes Colin and makes sure that his fruit does not
touch his pizzashes never seen a 7th grader get so upset about food
12:30pm Colin finishes lunch and goes outside with the rest of the students.
Colin loves to play football with the other boys. In fact, he fancies himself
quite the star of the lunchtime games (egocentrism). Colin is very tall for his
age and brings his football to school every day. The others boys laugh at
Colins antics right in front of him, but Colin never seems to get angry (difficulty interpreting body language, literal interpretationwithout regard to tone or



inflection in others). Today, Colin ran (slowly) after the boy he was supposed to
block, then attempted to block (threw himself at) another player. Colin missed
the player by a mile! However, Colin got up and said, Did you guys see that, I
was about two microns from flattening him like a pancake! (pedantic language).
Jared could not contain himself and replied, condescendingly, Oh yeah,
Colin, youre practically ready for the Super Bowl. Colin just beamed from
ear to ear (doesnt understand sarcasm).
Colin is in study hall. He knows he has homework in math, but
cant remember what page. Maybe he left his agenda in his locker? Wait, he
forgot to write the homework down in his agenda (executive function problems).
The teacher and Chenoa are discussing Chenoas science homework. Colin
goes right over and stands between the teacher and Chenoa and asks if he can
go to talk to his math teacher (interrupting/physical proximity).
Brad and two of his friends come home to find Colin playing his
favorite PlayStation 2 video game and eating a bowl of applesauce (fresh
apples are too crunchy). One of Brads friends asks if he can play for a while
with Colin. Without looking up, Colin nods yes (could be the response of a typical
boy playing a video game, or gaze avert). Colin beats Brads friend, and is able to
give the friend helpful tips about the game. After they are out of earshot, the
friend asks Brad why Colin doesnt have any friends over after school. Brad
replies, I guess because he doesnt have any real friends.

Chapter 7

Ellie and Dylan:

Ten Years Later

In our first book, Unlocking the Mysteries of Sensory Dysfunction, we felt it was
important to share our personal stories of having a child with sensory dysfunction. At the time we wrote these stories, Ellie and Dylan were five years
old and their sensory issues were at the core of our concerns, our routines, and
our decisions to seek further evaluation. In sharing their stories we hoped to
reach out to other parents and reassure them that they were not alone in facing
some of the unique challenges of parenting a child with sensory issues.
As our children have grown, our understanding of their sensory issues has
evolved. We wish to continue to share Ellie and Dylans stories. It continues to
fascinate us how they have grown to understand and cope with their individual sensory issues. It is this self-awareness of their sensory issues that has,
without a doubt, been the critical element in establishing their independence
and self-determination.
The past ten years have been full of surprises for all of us. Heres a glimpse
into where we have been and where we are now.
Ellies story (part one)
Following an uneventful pregnancy and delivery I was thrilled with the
arrival of my second daughter Ellie. It was a hot August and I envisioned




picnics in the park and walks with the double stroller. Yet, I sensed almost
immediately that there was something different about Ellie.
At Ellies two-month check-up her pediatrician asked me how everything
was going. I didnt realize how much I was struggling until I found myself
sobbing, She cries all the time and never sleeps. She gets so frantic in the car
seat that she scratches her face until it bleeds. She screams in the front carrier
and in the stroller. She doesnt nurse well and takes an hour to drink a bottle.
Without realizing it, I had already begun searching for answers. With the best
intentions, my pediatrician proceeded to remind me that some babies are
fussier than others and to simply be patient. I knew I wouldnt find an answer
that day.
I began reading every parenting book I could get my hands on and
cornered unsuspecting mothers at the playground. Willing to try anything, I
sought advice from family and friends. But, as I confided in a friend when Ellie
was a few months old, No matter what I do, I cant comfort her. I worry that I
will never have quality time with her older sister, Lindy, again. I cant get a
break because I cant leave her with a sitter. My husband doesnt understand
how I feel and thinks its just an extended post-partum depression. It was as if
someone had turned my world upside-down. Suddenly I found myself living
in a house of needy people and I had nothing left to give.
So I focused on Ellies next developmental step to provide that elusive
turning point in our lives...maybe when she can crawl, maybe when she can
feed herselfmaybe when she can walkYet, instead of a clear turn in the
road there were only rolling hills and deep valleys.
I knew from my first daughter that toddlers are unpredictable, but
nothing prepared me for Ellies intense mood swingshappy one minute,
huddled in a corner and hysterical the next. I lived on the edge, never
knowing when something would set her off. Usually I did not even know
what that something was. As a family we began to tread lightly around Ellie
knowing instinctively how weak the structure supporting her world was.
Everything was a battle: washing and combing her hair, brushing her teeth,
getting dressed, eating a meal, sharing a toy. Unlike her sister, who had shown
typical defiance, Ellies refusals to cooperate were desperate attempts at avoidance and completely devoid of reason. Not knowing what else to do, I
punished Ellie. She cried and I cried. These were not tears of anger or hurt, but
tears of sorrow. Ellie could not tell me what was wrong and I could not help
her. A chasm was developing across which neither of us could reach. Having
tried everything else, I stopped trying to fix Ellies life or to mold her into



the child I wanted her to be. In place of power struggles and tension, I gave
her my love unconditionally. I knew how desperately she needed this; little
did I know how much she deserved it.
At this time my third daughter, Julia, was born and in the increasingly
loud, hectic nature of our household, Ellie sunk into a state of despair. While
everyone played games at her older sisters birthday party, Ellie would sob on
my shoulder. When friends came over to play, Ellie wandered around
confused as if she did not know where to focus her attention. If the baby cried,
Ellie covered her ears and hid. The lukewarm bath water felt burning hot; she
couldnt tolerate the tags in her clothing; fell out of chairs; ran into furniture;
spilled juice getting the cup to her mouth and was terrified when the car
turned the corner. Deep down I knew that not only would I have trouble
finding answers, but that when I did, they would be far from simple.
The birth of my son Carter, coupled with Ellie beginning preschool,
finally gave me the means of comparison to validate years of concern. While I
was continually reassured that Ellie was the easiest child in the class, I had
only to sit and observe in the classroom to see that Ellie was indeed very different from the other children. Not only were there subtle developmental
delays, but there was an immaturity, an inability to prioritize stimuli, and a difficulty processing language. It was at this point that I stopped asking questions and began demanding answers.
By contacting the director of Special Education in my school district, I
was able to schedule a series of evaluations for Ellie. While fine motor and
speech delays were obvious leads during these evaluations the real answer I
had been looking for came with a call from New Hampshire. A friend had
heard about the trouble I was having with Ellie and wondered if she could ask
me a few questions. After an hour on the phone, I stood in disbelief when this
sensory integration specialist said, Liz, I think shes one of my kids. Here
was a woman who could accurately describe Ellies behavior without ever
having met her.
With this friends guidance, I was able to locate an occupational therapist
in my area, who is also trained in sensory integration. The success of Ellies
therapy has changed our lives.
How often I have wished I could go back in time and re-live those early
years with Ellie. If only I had known that her behavior was not the result of
stubbornness, but a sensory integration problem over which she had no
control. Those early years were a tough time not only for Ellie and me, but for
our family. For her siblings, it was a time of uncertainty.



We have also come to accept Ellie, as we have all children, for what makes
them special, not how well they fit into our mold. As a couple, Richard and I
were forced to accept the death of a dreama dream that we would have four
perfect children who would simply glide through life. But, both of us have
also been liberated from the confines of this very dream. For no child is perfect
and no child escapes lifes struggles. As a family we have been dragged unwillingly into the world of special education. However, it has also expanded our
horizons in a way we never knew was even possible.
(Adapted from Unlocking the Mysteries of Sensory Dysfunction by E. Anderson
and P. Emmons. Future Horizons Inc., 1996. Reproduced with permission.)

Ellies story (part two)

Time after time, I sat down to write this continuation of Ellies story and yet
the words just wouldnt come to me. Then I realized whyin my attempt to
simplify and condense almost ten years of her life, I was trying too hard to
compartmentalize it. Then I began to realize that neither Ellie nor any child
should ever be described using the nature of their special needs as a basis.
I remember Ellie so well at three years old receiving her initial evaluations.
I was watching through a one-way mirror at a diagnostic clinic when I heard
the psychologist ask, Ellie, are you a boy or a girl? Ellie just stared at her
blankly. So, she repeated, Ellie, are you a boy or a girl? Still no response. So
the psychologist tried again, Ellie, are you a boy or a girl? Finally, Ellie
looked at her and said, I Ellie. So, when I am asked to describe Ellie as a
teenager with a history of behaviors consistent with sensory integration dysfunction, PDD-NOS, ADHD, and a mood disorder, my first response is to say,
Really, shes Ellie.
It was when my fourth child, Carter, was born, and Ellie reached preschool age that I began to develop the means of comparison to validate years
of concern. While I was continually reassured that Ellie was one of the easiest
children in the class, I had only to observe in the classroom to see that Ellie
was indeed different from the other children. At that point, when I looked at
Ellie I saw a child with mild to moderate developmental delays with something else. During those early years, with the help of professionals, we started
teasing out what that something else was. There was no doubt in anyones
mind that Ellies delays, attention difficulties, and odd behaviors were based
in a sensory integration dysfunction. Sharing my experiences as the mother of



a child with sensory dysfunction in Unlocking the Mysteries of Sensory Dysfunction absolutely changed my life. I am a firm believer that it is in sharing that
you truly receive. The years I have spent in the role of parent and teacher
working with families, schools, agencies, and parent groups have defined, and
continue to define, who I am and what I am all about. The other day I was
driving in the car with Ellie and thinking about some of our toughest times
and some of our happiest times and I felt a deep sense of awe, because I knew
that I was given this child to guide me, to challenge me, to broaden my
thoughts, to encourage me to reach out to others, to learn, and to keep me
centered on my path. If it were not for Ellie, I wouldnt be who I am today, and
I am beginning to realize that if it werent for me Ellie would not be who she
isand this has taught me to marvel at the interconnectedness we all share in
this life.
Certainly over the past ten years, Ellie and our family have experienced
some very challenging times as a result of Ellies sensory, developmental,
attention, and social/emotional needs. Anyone who knows me, knows that I
dont gloss things over and try to stay based in what is real. Ellie has had
meltdowns in the middle of stores, broken favorite things, run away, physically hurt family members, struggled in school, and had difficulty with peer
relationships. But she has also shopped for hours for a special gift, created
beautiful works of art for others, and shown the ability to be warm and
responsive, made the middle school honor roll and made a good friend. These
are the complexities of Ellie and her unique needs. Certainly one of our
biggest challenges was nine long months spent on a waiting list for a psychiatric evaluation and services.
As Ellies needs have changed, so have our ways of supporting them. Ellie
no longer receives occupational therapy, speech therapy, or physical therapy,
or the services of a paraprofessional who for several years helped her keep
focused and stay organized, and helped with curricular and test modifications.
She does continue to receive services from a consultant special education
teacher as needed and receives counseling and medication monitoring
through a Child and Adolescent Health Center. This is not to say that it is not
sometimes a bumpy ridelost books, going to the wrong class, missing the
bus, getting lost, forgetting homework, not writing down assignments,
sensory overload. And there have been times when I still feel it is necessary to
step in and ensure that Ellies individual needs were being recognized
and met.



However, over the years, Ellies behaviors in our home did become
increasingly more challenging. To be honest, I guess they always have been
pretty challenging. Its just in the early years I figured all kids her age (especially those with her sensory needs) had equally challenging behaviors. Back
then, I focused almost exclusively on Ellies developmental delays. Perhaps it
was just easier and safer in some waysa fine motor delay?we knew what
to do; a speech delay?we knew what to do; a gross motor delay?we
knew what to do; learning difficulties?we knew what to do. But a daughter
who was manic, then depressed, anxious, agitated, perseverative, aggressiveI had no idea what to do. So, now I am learning and reading and reflecting and taking each day as it comes. My frustration lies in the fact that Ellies
needs were not simply developmental delays (that she would grow out of )
or exclusively sensory integration dysfunction. The irony here is that her
sensory dysfunction has improved dramatically and really has become a much
smaller piece. However, now I feel in many ways like I am back at square
onepartnering with the school, nurturing peer relationships, and taking a
different approach to the behavior piece. Right now we are in a good place.
Ellie is stable, doing well at school, has a couple of new friends, and is
involved in several activities. Shes happy and that is the most important thing
to me.

Dylans story (part one)

After a trying pregnancy and a difficult delivery, Dylan was born to two
elated, yet weary, parents. Right from the beginning, however, Dylan found
touch aversive. He wanted Mom or Dad to be within sight, but did not wish to
be cuddled. Dylan was constantly wakeful, taking only 20 minute power
naps throughout the day and night. It was not until sometime later that I
realized only 100 percent cotton clothing and NO blanket would result in his
sleeping for longer than five minutes. Strangely, Dylan never became agitated
when he was physically cold; he enjoyed it. For example, baths were
lukewarm at best, otherwise, he would scream as though he were boiling in
oil. Similarly, if his bottle or food were even warm, they would be rejected.
Throughout Dylans infancy, I thought of myself as a first-time parent
struggling with a difficult baby, or that was what I was told time and time
again by the people I was looking to for advice. Yet, even with these reassurances, I knew in my heart that the truth was not that simple.



When Dylan reached the toddler years his odd behaviors became even
more pronounced. No longer was he just quirky. A strong feeling that something was really wrong began to gnaw at me daily as I witnessed Dylans
sensory problems amplify. While Dylan continued to demand cold food, cold
baths and cold sleeping conditions, now anything with even a remotely
crunchy texture would also be rejected. In addition, washing Dylans hair was
akin to a world class wrestling event. Because it was such an ordeal, my
husband flatly refused to bathe Dylan, and even avoided feeding him. I was
appalled to realize that I no longer served hot meals! Dylans sensory integration disorder had come to rule our lives, and we had never even heard of the
Unlike many other children with sensory integration disorder, Dylan
reached most of his developmental milestones early. He crawled, sat with a
straight back and cruised, all on the day he turned seven months. By nine
months Dylan was chasing the dog around the house at break neck speed.
When he was 17 months old, his sister Laura was born. While I was in the
hospital, Grandma cared for Dylan and remarked, He is so brighthe
knows all his colors and shapes, and can recite the alphabet. He even tells me
what he or the dog wants to eat for lunch. But he does act strangely for a
When the new baby got into a routine, I began to compare her behaviors
to Dylans at the same age, and grew increasingly alarmed. By the time Dylan
was two and a half, I began actively seeking help. I was not sure exactly what
was wrong, but I knew that some form of intervention was needed. The first
two or three professional sources I sought out were less than helpful. The
tacit inference was that I wanted a perfect child and was therefore looking for
something to be wrong. My break finally came when a non-judgmental
neighbor suggested that if I had concerns regarding a preschool child, I
should contact the local Early Childhood Direction Center. I did just that the
next day and was relieved to have an informed and sympathetic ear. I was
instructed to phone a local agency, and speak with someone about having
Dylan evaluated by a developmental specialist and an occupational therapist.
Appointments for the evaluations were set up, and much to my surprise, they
were performed at no cost to me.
At age three, Dylan began receiving occupational and physical therapy
several times a week as a direct result of the evaluations he had undergone. As
a preschooler, his sensory integration problems had become more defined and
easier to pinpoint. It was also at this time that Dylan became one of the



luckiest children in the world of therapy. His occupational therapist, Eileen,

thought he was special. She loved him, and in turn Dylan absolutely
adored her.
It was Eileen who assured me that I was not crazy when I described Dylan
as being wired differently. In fact, I was shocked when Eileen would ask very
pointed questions about Dylans behaviors and then respond, Thats what I
thought you would say. She knew that even though Dylan hated to be
touched, loathed swings, and practically went unconscious when asked to
ride a see-saw, he would seek out certain sensations in an almost obsessive
way. This is a child who would not drink carbonated beverages, eat crunchy
cookies, or consume a hot meal. Yet, the longer and faster the slide, the better.
He loved the feel of the porcelain tub and actually asked to sleep there. But,
this same child reacted to the rubber, textured bath mat in this tub as if it were
a bed of thorns.
Dylan has waded out into the Atlantic Ocean with open blisters on his feet
and not noticed whether his feet hurt or not. However, after his father
placed bandages over these blisters, Dylan screamed hysterically for ten
minutes, and a stranger from a neighboring cottage came over to ask if we
needed help. At this point we removed the bandages and Dylan stopped
screaming. Just as he has a different awareness of pain, Dylan acts as though
his legs are detached. During baths, he will frequently ask, Mommy, have my
legs been washed yet? to which I reply, Honey, I just soaped them up and
rinsed your legsall done!
One of my favorite sensory integration stories about Dylan occurred
when he was five years old. Dylan, Laura and I were at the local YMCA
signing up for a class when things started getting out of hand and I asked
them to please put their coats on NOW (before we were asked to leave)! A
couple of minutes later I looked up from my paper work to see and hear a
small crowd gathered around a child having a very loud tantrum. At that
moment I realized that it was my son! I calmly walked over amidst the glares
and asked Dylan what was wrong. He replied through the sobs, Mommy, you
told me to put on my coat, but I cant find it anywhere. It was at this point that
I said to Dylan, Look on your back, youre already wearing your coat. Dylan
looked at his arms, saw his coat and replied, Oh, Im glad its not lost! and
promptly stopped crying.
Dylan has worked very hard to overcome his sensory integration
problems and has come a long way as a result of this hard work. Our family
has also struggled. I think that we all realize now that our life will never be



completely normal, and thats okay. As a family we have made many sacrifices, but we have also made many gains. As a result of living with this
disorder, Dylan and his sister Laura have developed great empathy for all
people. They bring this compassion into every aspect of their lives. My
husband and I have navigated through storm after storm and have not lost
sight of the truththat we have two wonderful kids and not everyone needs a
hot meal.
(Adapted from Unlocking the Mysteries of Sensory Dysfunction by E. Anderson and P.
Emmons. Future Horizons Inc., 1996. Reproduced with permission.)

Dylans story (part two)

Dylan was diagnosed with Aspergers syndrome at the age of six, after three
other comprehensive evaluations had concluded that Dylan was most likely
ADHD with some motor delays and a few quirky behaviors. Dylan has
grown into a handsome teenager who is still active and quirky, but who is
also well liked and hard working. Here is a little snippet from events that
transpired a few summers ago.

Ordinary for a day

Mom, why cant I be normal? I pray every night that God will make me
ordinary for just one day. Then I would be able to figure it out.
Im too weary for this question at the end of a sultry August day. I only
want to get home and sit in front of a fan.
Figure what out, Dylan?
You know, Mom, how to be like the regular kids at camp. I mean, I know
I have autism, but Im a lot more like the regular kids than I am the autistic
kids. If I could be ordinary for a day, I would learn all the strategies for getting
a friend and I would write them down so I wouldnt forget when I returned to
being autistic the next day. Maybe God is waiting until next year when Im
Then, in characteristic style, Dylan jumps into the car, takes his action
figures out of his backpack and begins to repeat, verbatim, scenes from the
1960s Batman series. As I drive, I reflect on the conundrum that sits next to
me. Here is a child who could speak in full sentences, knew all of his shapes,
colors, and animal sounds by the age of 17 months, and yet cannot navigate
the social world enough to develop or maintain a friendship.



I break from my stunned silence, attempting to reenter the conversation.

Dylan, you have friends at school and camp.
Mom, did you know that the Siberian tiger is the largest member of the
cat family and is the only big cat that is indigenous to North America?
I learned a long time ago that poor conversational skills, topic perseveration, and inappropriate responses are hallmarks of the mild form of
autism that Dylan has, called Aspergers syndrome. I very pointedly bring
Dylan back to the original topic: I said I thought you had friends at school
and camp.
Dylan, eyes downcast, still playing with the Batman action figure,
responds very matter of factly, I dont have anybody who fits the definition of
a REAL friend.
Well, whats the definition of a real friend? I ask.
At this point, I was fully expecting a dictionary definition of the word
friend. Instead, Dylan said, in his characteristically monotone voice, Mom,
friends are people who want to be with you, even when they dont have to.
Friends call each other up on the phone, friends invite you over to play at their
house, and friends have sleepovers and birthday parties. Nobody has ever
invited me to a sleepover. Nobody ever wants to come to my house even
though I ask them all the time.
Now its my turn to change the subject in midstream, Hey, what do you
say we go to McDonalds and get a little treat before we pick your sister up
from her camp? The truth is that the lump in my throat is so big, that if I allow
myself to start crying now, I will be unable to drive.
As I pull into those Golden Arches, my mind starts to call up vivid images
and vignettes of Dylans early childhood. I can see the cherubic baby who
screamed when swaddled, never slept for more than 20 minutes at a time, and
who refused to eat warm foods. I remember with horror the loquacious
toddler who howled and tantrumed when we went to the park because he
hated the swings, merry-go-round and sandbox so much. I recall the discriminating (ultra picky) eater, who would refuse a piece of pizza shaped like a
triangle, but would eat the same slice if it were cut into squares. How could I
forget the fascination with construction equipment, which eventually faded
into an obsession with Batman, which was, over time, eclipsed by a need to
learn, talk, think, and read about the Japanese language and the origin of
Ninjas? Presently, his area of intense interest is writing and reading
action/adventure stories and poetry.



My reminiscence is interrupted by an angry wail, Stupid, stupid seatbelt!

I can never unbuckle itIll never be able to unbuckle it
As I lean over to assist him, Dylan looks plaintively at me and says, Do
you remember when I was four years old and I asked you what did I do wrong
when I was in your uterus to make me so different?
Vaguely, I lie (the whole conversation was permanently etched in my
psyche). What made you think of that right now?
Can I have a double cheeseburger meal, Im really hungry.
No, this is just a snack, and why did you ask about when you were four?
Just as we approach the counter, Dylan growls, You never let me have the
double cheeseburger meal. You said I could have a treat.
Dylan is rapidly beginning to meltdown, so I usher him out of the queue
and begin to speak to this tall eleven-year-old, who has the vocabulary of an
adult, and the emotional development of a five-year-old. Dylan needs
prompting to lower his voice, look at me, and not become completely distraught because he is not getting a double cheeseburger meal.
The good news is that I have learned to hone in on the problem rapidly: it
is usually the wording. What exactly is bothering you? I said we were
stopping for a little treat.
Dylan responds without missing a beat, Thats exactly it, first you said
treat, then you changed it to snack. A treat is something special that you
dont get very often. A snack means a small amount of food.
This is a prime example of the way children with Aspergers interpret
language very literally. I remember the time Dylan came home from 1st grade
with different clothes on because he had spilled paint in art class. That night,
when I asked him to take off his clothes and get into the tub, he just stood
there like a zombie, then started to cry. When I asked him why he was crying
instead of taking his clothes off, he said, These arent my clothes, these are
nurses office clothes! From that moment on, I became very conscious of the
disparity between Dylans superficial language skills (adult-like vocabulary,
sentence structure, and syntax) and his ability to comprehend language. I later
learned that abstract concepts like emotions, and subtle conversational cues
such as body language and facial expressions are very difficult for children
with Aspergers syndrome to interpret.
Thus, I shift to plan B. Dylan, what I meant was, that you could have
either a hamburger or a milkshake, as a snack-sized treat.
Oh, then Ill have a chocolate shake.



I quickly place our order and we find a table in the middle of the crowded
dining area. Dylan happily guzzles his shake while I bite into my burger.
Gee, Mom, I guess youve abandoned the Weight Watchers plan, huh?
Did I mention that children with Aspergers have a real deficit in the social
skills arena? I pointed out to Dylan that the comment he just made could be
construed as unkind. He was very surprised. Oh, I didnt mean to hurt your
feelings, I was just making an observation. You keep telling me not to just talk
about myself all the time. Conversation is so confusinghow does everybody else keep the rules straight? Dylans frustration was obvious and heartfelt.
That night, when I tucked the kids into bed, I thought about Dylans
world. The world of a child who has Aspergers syndrome; a child who has
always been ruled by his inflexibility and anxiety.
From the ages of three to five, when other kids his age were playing,
napping, or watching Mr. Rogers, Dylan was spending Monday through
Friday afternoons in the Rehabilitation Department of a local hospital receiving speech therapy, occupational therapy, and physical therapy. When the
other kindergartners were playing together and making friends, Dylan was
lost in the fray, trying hard to participate in a world he could only partially
understand. During early elementary school, he was the really smart, but
weird kid, who needed a paraprofessional to help him keep himself together
and navigate the social world. As Dylan grew and became more socially
aware, he longed for friendships and a sense of belonging within his peer
group. I honestly feel that no child has worked more purposefully or intensively to overcome his deficits than Dylan. He has hung in tenaciously, experiencing one social disaster after another, with successes being few and far
Now, Dylan is twelve and attends middle school. If middle school is a
social and developmental nightmare for the average child, it is a social black
hole for a child with autism. Dylan knows that, because of his autism, he must
work harder than his peers to maintain himself and get through the school
day. Fortunately, Dylan has persevered so far. He still needs a paraprofessional
to help him with the social labyrinth of school, but he is fully included in
regular education and takes some advanced academic courses. He has even
earned his red belt in karate, learned to play the piano, and is a member of the
concert choir.



However, the best news of all came just yesterday. Dylan was invited to his
first ever sleepover! When I asked him how he felt about that, he stammered,
through tears, I think this must be what it feels like to be an ordinary kid.
We recognize that life is dynamic and we dont know where Ellie and Dylan
will be ten years from now. But, what we are sure of is that Ellie and Dylan are
a couple of great kids who are becoming aware of who they are and are developing the tools they will need to navigate their futures.

In Conclusion

All of us process sensory input 24 hours a day, starting from the moment we
are born. It is the integration of this sensory information that shapes our perceptions, defines our realities, and drives our behaviors. We all exist as sensory
beings, with our own unique perspectives. We hope that this book promotes a
greater awareness and understanding of sensory issues and sensory integration dysfunction. Sensory issues and sensory integration dysfunction touches
all of our lives in some waya child, a student, a family member, a coworker,
or a friend who has an autism spectrum disorder, ADHD, a learning disability,
or cerebral palsy. It is our opinion that the sensory piece for many children has
been overlooked, downplayed, or undervalued for too long. Now is the time
to bring sensory dysfunction into the forefront and begin to look at home and
school, learning and behavior differentlythrough a sensory lens.


Appendix 1

Sensory Integration Activities

The Tactile System

Feely box
Use a plastic container, pillow case or shoe box. Place different objects in the container and have the child reach in and guess what object he or she is touching.

Sensory bin
Fill a large plastic container with rice, pasta, corn meal, popcorn, sand, water,
birdseed, etc. and place different objects in it. Have child use hands to sort and sift
through to find objects. Try different materials that are warm, cold, bumpy,
smooth, etc.

Dress-up clothes
Keep a box of hand-me-downs or yard sale dress-up clothes. Look for items that
have different textures (silky, furry, feathers, etc.), colors, patterns.

Bathtub play
Encourage your child to use different soaps and sizes and types of towels while in
the tub. Offer different soaps, scented, oatmeal soap, shaving cream, lotion soap,
animal shapes, foam soap, exfoliating body wash. Offer different types of textures
for washing: thick wash cloths, soft, plastic brushes, kitchen sponges, foam pot
scrubbers, handi-wipes, loofa sponges, bath mitts, etc.

Offer the child toys with different texturessquishy, hard, rough, smooth,
bumpy, soft, etc.




Make a hotdog in a bun

Roll the child up tightly in a blanket.

Cook together
Anything that allows the child to mix something hands-on such as cookie
dough, bread dough, cake batter, pizza dough, spreading toppings.

Fingerpainting activities
Use finger paint and mix in other materials to get a different sensory experience,
for example, rice, sand, seeds, popcorn, etc. Or make your fingerpaint by using
pudding, shaving cream, or Jello on a cookie sheet or tray.

Encourage the child to try new foods with different tastes and textures.
The Vestibular System

A Hippity Hop is a large ball with a handle that child sits on and hops and
bounces. Try it on grass and carpet.

Roll down a grassy hill.

Playground swings, tire swings, rope swings, monkey swings, trapeze, rings.

Swinging in a blanket
Have child lie down on a large blanket. Have two adults hold opposite corners of
the blanket, pick up child in blanket slightly off the floor or ground and swing.

Playground slides, swimming pool slides, sledding.



Obstacle course
Set up an obstacle course at home (inside or outside) that encourages crawling,
climbing, jumping, balancing, etc.

Riding vehicles
Tricycles, bicycles, scooters, Kettle cars, big wheel, child-size motorized vehicles.

Game of tag, foot races, kickball, T-ball, soccer, different kinds of ball games.

From a high place to a lower place (bottom stair), jumping in place, jump rope,
standing broad jump, running broad jump, trampoline, jumping jacks, hop
scotch, jumping in a pile of leaves.

Supervision requiredthese activities may result in intense sensory input
merry-go-round, sit n spin, twirling.
The Proprioceptive System

Carry heavy things

Laundry basket, grocery bag, gallon of milk, container of laundry detergent.

Pushing activities
Strollers, child-size grocery cart, toy lawn mower, toddler push toys, carry
knapsack filled with toys, etc.

Pulling activities
Wagons, tug-of-war, toddler pull toys.

Crashing activities
Set up couch cushions, pillows, comforters, and allow child to jump into them,
Velcro walls, bumper cars.



Crab walk
Wheelbarrow walk
Allow the child to pour from different size and shape containers into another
container. For example: water, sand, rice, pasta, seeds, popcorn, etc.

Spreading activities
Allow child to spread his or her own peanut butter, jelly, fluff, cream cheese.

Hanging activities
With close adult supervision and/or support, have the child use the monkey bars
at the playground.

Push place
Designate a spot in your house or classroom where the child can push with hands
or feet against a wall.

Batting/swinging activities
Baseball, golf, tennis, racquet ball, etc.

Appendix 2

Treatment Options

The following options are currently being utilized for the treatment of sensory
dysfunction. Our belief is that it is up to parents to become the ultimate
consumerreading, asking questions, and making informed decisions about
any form of intervention that their child may receive. We also strongly recommend that any treatment option you wish to explore be discussed with and supervised by the appropriate professional(s).
There are many different treatment options available for the environmental, food,
and chemical sensitivities that some believe are associated with sensory dysfunction. Some of these include dietary changes, food elimination, modifications to
the physical environment, or desensitization protocols.
Auditory integration training
Originally developed by a French physician, Dr. Berard, this treatment option
makes use of different sound frequencies to exercise the ear in order to desensitize
and improve hearing and communication skills.
Behavior modification
There are many different forms of behavior modification paradigms. These
methods typically break behaviors down into component parts and apply
specific structured techniques to modify, change, or shape those behaviors.
Brushing protocol
A brushing program which utilizes a surgical brush to brush an individuals
arms, hands, back, legs, and feet in an attempt to help the individual process and




organize sensory information. This brushing is followed by joint compressions

where each joint is supported as pressure is applied to it. This treatment approach
was developed by an occupational therapist, Patricia Wilbarger.
Promotes the use of natural ingredients and organic materials to treat illnesses to
attain or maintain good health and development.
Oral tactile stimulation
In this option, a finger, wrapped in a wash cloth, or a Nuk massager is used to
swipe across the roof of an individuals mouth from side to side three times
quickly, then exiting the mouth. This treatment option is used before and during
each meal as is tolerated. It is designed to stimulate the mouth for increased
awareness/decreased awareness of oral sensory stimulation.
Centers around physical manipulation of the body and the use of natural and
homeopathic remedies to attain or maintain good health and development
and/or treat illness (e.g., chiropractic).
Sensory integration therapy
The goal of sensory integration therapy is to facilitate the development of the
nervous systems ability to process sensory input in a more normal way through
addressing the vestibular, proprioceptive, and tactile systems.

Appendix 3


American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition. Washington, DC: American Psychiatric Association.
Anderson, E. and Emmons, P. (1996) Unlocking the Mysteries of Sensory Dysfunction.
Arlington, TX: Future Horizons Inc.
Ayres, A.J. (1979) Sensory Integration and the Child. Los Angeles: Western Psychological
Frith, U. (1991) Asperger and his Syndrome. In U. Frith (ed) Autism and Asperger
Syndrome. Cambridge: Cambridge University Press.
Heward, W. (1996) Exceptional Children. Upper Saddle River: Prentice Hall Inc.
Learning Disabilities Association of America (2005) Learning Disabilities: Signs,
Symptoms and Strategies. Pittsburgh, PA: Learning Disabilities Association of
Siegel, B. (1996) The World of the Autistic Child: Understanding and Treating Autistic
Spectrum Disorders. New York: Oxford University Press.
University of the State of New YorkThe State Education Dept Office of Vocational
and Educational Services (2004) Individual Evaluation and Eligibility Determinations
for Students with Disabilities. Albany, NY: New York State Department of Education.


academic achievement,
difficulties 32, 34
activities, sensory
integration 123, 16568
activity levels, high/low 323,
adaptive equipment 124
adaptive skills development 51,
aggression 97, 99
allergies 169
arena style evaluation 63
aromas 124, 125
Aspergers syndrome 10, 68, 69,
712, 13050
case study 1317, 14750,
diagnosis 1308
example of a daily
routine 14750
language deficits of 137,
school and 96
social interaction
difficulties 71, 1317,
13850, 1557
symptoms 1318
assessment and
evaluation 2931, 5564
formal 63
information 569
individual 63, 656
informal 634
programs and services 646
psychological 61
role of 601
and symptom
pervasiveness 556
terminology 614
attention deficit disorder
(ADD) 73
attention deficit hyperactivity
disorder (ADHD) 9, 10, 68

case study 1547

combined type 73
definition 734
type 73
inattentive type 73
attention-seeking behaviors 117
audiology assessments 62
auditory defensiveness 3640
auditory dysfunction 3640, 80,
11415, 120
auditory integration training 169
autism spectrum disorders 9, 68
definition 6972
visual schedules for 834
see also specific disorders
autistic disorder 17, 6971
atypical autism 71
awareness of sensory
needs 1245
Ayres, J.A. 9, 1416, 34
babies 64
adaptive skills
development 53
difficulties 51
milestones 213
signs of sensory
dysfunction 413
balance problems 356
bathing/showering 1278, 165
bedtimes 129
behavior modification 169
behavioral management
strategies 11822
helpful 11820
preventative 122
unhelpful 1212
Berard, Dr. 169
bipolar disorder 74
physical 122
body language 143, 1489
brushing protocol 16970


case studies 10, 18, 3641

syndrome 1317,
14750, 1547
Dylan 10, 567, 151,
elementary school
children 86, 903
Ellie 10, 1516, 163
middle/high school
children 86, 937
preschoolers 8690
central auditory processing
disorder 10, 72
central nervous system 1516
plasticity 16
challenging behaviors 32, 34
management techniques
for 11622
as means of
communication 979
misunderstanding 11718
and teaching
modifications 112, 114
childhood disintegrative
disorder 69
diagnoses) 55, 6775
cognitive development
problems 513
color 1234
communication difficulties 512
of autistic disorder 70
in babies 423, 51
managing children
with 11617
recording 103
in toddlers 456, 52
cooking 166
coordination 1920
difficulties 17, 32, 33,
cravings, sensory 82
criterion-referenced tests 63
curricular adaptations 106,


daily routines 3640

defining sensory
dysfunction 3266
development 208, 2931,
developmental screenings 65
diagnosis 59
Aspergers syndrome 1308
discriminatory touch 38
displeasure, expression of 121
distractibility 97, 98
do as I do 119
dreamers 114, 115
dressing 128, 165
DSM-IV (Diagnostic and Statistical
Manual of Mental Disorders,
Fourth Edition) 55, 69, 73,
dyscalculia 72
dysgraphia 72
dyslexia 72
dyspraxia 72
early intervention 645
egocentrism 149
emotional development 289
emotional difficulties 423,
456, 54, 1345, 148
emotional lability 97, 98
modifications 1227
ethnicity 60
facial expressions 83, 143, 148
feely box 165
fingerpainting 166
food 129, 166
forms, school 1028
frustration levels 97, 98
gaze avert 144, 148, 150
generalization difficulties 1467,
gustatory symptoms 36, 37, 38,
hand pouches 81
headphones, noise-muffling 80
hidden disorders 67

home management
techniques 11629
partnerships 99101
homeopathy 170
homework 937
honesty, inappropriate 156
hula hoops 81, 83
hyper activity 323, 978
hypo activity 323, 978
icons 834
if, then statements 119
ignoring, planned
(extinction) 121
intelligence quotient (IQ ) 61
interrupting 90, 1401, 148,
jogging 167
jumping 114, 167
language difficulties 512
in Aspergers 137, 13847
delays 32, 33
evaluation 62
pedantic language 13940,
148, 150
learning disabilities 9, 10, 68,
723, 112
learning style adaptations 106,
lesson plans 11315
lighting 124
literal interpretations 1456,
149, 156
management techniques 11629
behavioral 11822
environmental 1227
self-care strategies 1279
see also treatment options
medication 75
meltdowns 578, 156
modeling behavior 119
motor skills 32, 346, 545, 62,
multidisciplinary teams 635
muscles 20, 36
music 124


needs of the child 61

noise 124
non-compliance 97, 98
nonverbal behavior
impairments 1312
nonverbal consequences 1212
norm-referenced tests 63
notebooks 569
nurses, school 80
obstacle courses 167
occupational therapy 79
evaluations 61, 623
in school 85, 86
olfactory dysfunction 39, 82,
oral tactile stimulation 170
osteopathy 170
over-reactive children 17, 32, 33,
paraprofessionals 789, 96, 97,
1:1 paras 79
peer relationships 1323
perception 19
perseveration 97, 98, 148, 154
pervasive developmental disorder,
not otherwise specified
(PDD-NOS) 69, 71
pervasive developmental
disorders 69
physical education instructors,
adapted 79
physical proximity issues 978,
physical therapy 62, 79, 856
play, impoverished 1367
point of view (POV), of the
child 86, 88, 91, 945
pokers 114, 115
pragmatics 13850
preschoolers 267
adaptive skills
development 53
difficulties 52
preparing children to
learn 10910
in preschool class 8690



services for 656

signs of sensory
dysfunction 468
preventative behavioral
strategies 122
programs and services
assessment for 646
early intervention 645
eligibility for 66
preschool age 656
proprioceptive system 19, 20,
and school life 85, 114,
sensory integration activities
for 1678
prosody, odd 141, 142, 148
psychological evaluations 61
psychologists, school 80
pull-out/push-in therapy 79
rapport between home and
school 99
reciprocity, lack of
social/emotional 1345, 148
record keeping 569
gears 11819
reinforcement 105, 119
relaxers 105, 1234
response prevention 120
restricted interests 701, 1357,
Retts disorder 69, 71
riding bikes 167
righting a wrong 120
routines 3640, 123, 126, 129,
runners and hiders 97, 98
running 167
school 76115, 11629
adapting to the
child 10115
challenging behavior as
means of communication
in 979
elementary 86, 903
partnerships 99101

lesson plans 11315

middle/high school 86,
937, 11011, 157
parental roles 76
personnel 7880, 100
preparing children to
learn 10911
students 111
sensory dysfunctions
in 806
situations and
solutions 806
special education 778
teachers role 76, 78,
modifications 11115
school forms 1028
abbreviated secondary
school form 108
basic child information
form 102
classroom management
form 105
communication abilities
form 103
learning style/curricular
adaptations form 106
motor needs/adaptations
form 104
work samples form 107
school-aged children 278,
self-calming behaviors 11718
self-care strategies 62, 1279
self-concept, poor 32, 34
self-monitoring, students 111
sensory activities 123, 16568
sensory approaches 61
bags/baskets/bins 1267,
sensory cravings 82
sensory defensiveness 17
sensory integration 1431
adaptive behavior and 16
definition 14
development 208, 2931
drive for 16

history of 1416
and reality 19
sensory processing 1619
sensory systems 1920
sequential, hierarchical
development 16
and social and emotional
development 289
sensory integration therapy 170
sensory interpretation 18
sensory modulation 17
sensory needs, awareness
of 1245
sensory orientation 18
sensory overload 38, 119
sensory processing 1619
sensory registration 17, 18
sensory response 17, 18
sensory systems 1920, 346
see also proprioceptive
system; tactile system;
vestibular system
services see programs and services
sharing 1334, 152
shouters 114
shut down 97, 98
sign language 83
slow gear kids 8690
social difficulties 54
in babies 423
interactional 6970, 71,
13150, 1557
in toddlers 456
social history 61
social interaction 289
in Aspergers syndrome 71,
13150, 1557
in autistic disorder 6970
social misfits 137
social stories 81
social workers, school 79
special education 778
speech delays 32, 33
speech evaluation 62
speech therapy 79
stereotyped behaviors 70, 71,
stimulation, level of 1223


stopping behavior before it

starts 11920
student portfolios 101
study guides/outlines 83
symptoms/signs of sensory
dysfunction 324, 515
in babies 413
pervasiveness 556
in preschoolers 468
school-aged child 4850
in toddlers 446
tactile system 19, 35, 3640
school and 801, 115
sensory integration activities
for 16566
tactilely defensive children 801,
taking a break 120, 126
analyzing the situation 86,
889, 912, 95
describing behavior 86, 87,
901, 93
as detectives 8699
never forgets factor 86, 88,
91, 94
point of view of the
child 86, 88, 91, 945
pre-behavior situation 86,
88, 91, 94
role 76, 78
special education 77, 78
strategies 86, 8990, 923,
temperament 28
texture 36, 3840, 81, 124
time out 121
toddlers 246
adaptive skills
development 53
difficulties 456, 52
early intervention 64
signs of sensory
dysfunction 436
toothbrushing 128
topics, staying on 1423, 148
touch see tactile system

touchers 114, 115

toys 81, 165
transitions 105, 124
treatment options 16970
see also management
techniques; medication
turn taking 140, 148
under-reactive children 17, 32,
33, 8690, 109
verbal warnings 80
vestibular system 19, 3541
and school life 856
sensory integration activities
for 1667
visual assessment 62
visual barriers 125
visual cues 125
visual dysfunction 379, 824,
114, 115
visual school schedules 834
visual supports 125
visual-motor skills 62
inflection 142
modulation difficulties 141,
sing-song 141, 142
whole child 601
Wilbarger, P. 170